18 DE Admin. Code 1501. Medicare Supplement Insurance Minimum Standards

In the case of an individual Medicare supplement policy, the person who seeks to contract for insurance benefits, and

In the case of a group Medicare supplement policy, the proposed certificate holder.

Health insurance coverage;

Part A or Part B of Title XVIII of the Social Security Act (Medicare);

Title XIX of the Social Security Act (Medicaid), other than coverage consisting solely of benefits under section 1928;

Chapter 55 of Title 10 United States Code (CHAMPUS);

A medical care program of the Indian Health Service or of a tribal organization;

A state health benefits risk pool;

A health plan offered under chapter 89 of Title 5 United States Code (Federal Employees Health Benefits Program);

A public health plan as defined in federal regulation; and

A health benefit plan under Section 5(e) of the Peace Corps Act (22 United States Code 2504(e)).

Coverage only for accident or disability income insurance, or any combination thereof;

Coverage issued as a supplement to liability insurance;

Liability insurance, including general liability insurance and automobile liability insurance;

Workers’ compensation or similar insurance;

Automobile medical payment insurance;

Credit-only insurance;

Coverage for on-site medical clinics; and

Other similar insurance coverage, specified in federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits.

Limited scope dental or vision benefits;

Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; and

Such other similar, limited benefits as are specified in federal regulations.

Coverage only for a specified disease or illness; and

Hospital indemnity or other fixed indemnity insurance.

Medicare supplemental health insurance as defined under section 1882(g)(1) of the Social Security Act;

Coverage supplemental to the coverage provided under chapter 55 of title 10, United States Code; and

Similar supplemental coverage provided to coverage under a group health plan

gulations.

Coverage only for a specified disease or illness; and

Hospital indemnity or other fixed indemnity insurance.

Medicare supplemental health insurance as defined under section 1882(g)(1) of the Social Security Act;

Coverage supplemental to the coverage provided under chapter 55 of title 10, United States Code; and

Similar supplemental coverage provided to coverage under a group health plan.

Coordinated care plans that provide health care services, including but not limited to health maintenance organization plans (with or without a point-of-service option), plans offered by provider-sponsored organizations, and preferred provider organization plans;

Medical savings account plans coupled with a contribution into a Medicare Advantage plan medical savings account; and

Medicare Advantage private fee-for-service plans.

The definition shall not be more restrictive than the following: “Injury or injuries for which benefits are provided means accidental bodily injury sustained by the insured person which is the direct result of an accident, independent of disease or bodily infirmity or any other cause, and occurs while insurance coverage is in force.”

The definition may provide that injuries shall not include injuries for which benefits are provided or available under any workers’ compensation, employer’s liability or similar law, or motor vehicle no-fault plan, unless prohibited by law.

Hospitalization – Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.

Medical Expenses – Part B coinsurance (generally 20% of Medicare-approved expenses) or co-payments for hospital outpatient services. Plans K, L and N require insureds to pay a portion of Part B coinsurance or co-payments.

Blood – First three pints of blood each year

an, unless prohibited by law.

Hospitalization – Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.

Medical Expenses – Part B coinsurance (generally 20% of Medicare-approved expenses) or co-payments for hospital outpatient services. Plans K, L and N require insureds to pay a portion of Part B coinsurance or co-payments.

Blood – First three pints of blood each year.

Hospice— Part A coinsurance

A | B | C | D | F | F* | G | K | L | M | N

Basic, including 100% Part B coinsurance | Basic, including 100% Part B coinsurance | Basic, including 100% Part B coinsurance | Basic, including 100% Part B coinsurance | Basic, including 100% Part B coinsurance* | Basic, including 100% Part B coinsurance | Hospitalization and preventive care paid at 100%; other basic benefits paid at 50% | Hospitalization and preventive care paid at 100%; other basic benefits paid at 75% | Basic, including 100% Part B coinsurance | Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER

Skilled Nursing Facility Coinsurance | Skilled Nursing Facility Coinsurance | Skilled Nursing Facility Coinsurance | Skilled Nursing Facility Coinsurance | 50% Skilled Nursing Facility Coinsurance | 75% Skilled Nursing Facility Coinsurance | Skilled Nursing Facility Coinsurance | Skilled Nursing Facility Coinsurance

Part A Deductible | Part A Deductible | Part A Deductible | Part A Deductible | Part A Deductible | 50% Part A Deductible | 75% Part A Deductible | 50% Part A Deductible | Part A Deductible

Part B Deductible | Part B Deductible

Part B Excess (100%) | Part B Excess (100%)

Foreign Travel Emergency | Foreign Travel Emergency | Foreign Travel Emergency | Foreign Travel Emergency | Foreign Travel Emergency | Foreign Travel Emergency

*Plan F also has an option called a high deductible plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year [$2000] deductible

ble | Part B Deductible

Part B Excess (100%) | Part B Excess (100%)

Foreign Travel Emergency | Foreign Travel Emergency | Foreign Travel Emergency | Foreign Travel Emergency | Foreign Travel Emergency | Foreign Travel Emergency

*Plan F also has an option called a high deductible plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year [$2000] deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses exceed [$2000]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible. | Out-of-pocket limit $[4620]; paid at 100% after limit reached | Out-of-pocket limit $[2310]; paid at 100% after limit reached

Benefits | Plans Available to All Applicants | Medicare first eligible before 2020 only

A | B | D | G1 | K | L | M | N

C | F 1

Medicare Part A coinsurance and hospital coverage (up to an additional 365 days after Medicare benefits are used up) | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ | ✔

Medicare Part B coinsurance or Copayment | ✔ | ✔ | ✔ | ✔ | 50% | 75% | ✔ | ✔ copays apply 3 | ✔ | ✔

Blood (first three pints) | ✔ | ✔ | ✔ | ✔ | 50% | 75% | ✔ | ✔ | ✔ | ✔

Part A hospice care coinsurance or copayment | ✔ | ✔ | ✔ | ✔ | 50% | 75% | ✔ | ✔ | ✔ | ✔

Skilled nursing facility coinsurance | ✔ | ✔ | 50% | 75% | ✔ | ✔ | ✔ | ✔

Medicare Part A deductible | ✔ | ✔ | ✔ | 50% | 75% | 50% | ✔ | ✔ | ✔

Medicare Part B deductible | ✔ | ✔

Medicare Part B excess charges | ✔ | ✔

Foreign travel emergency (up to plan limits) | ✔ | ✔ | ✔ | ✔ | ✔ | ✔

Out-of-pocket limit in [2019] 2 | $5,560 2 | $2,7802

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61st thru 90th day 91st day and after: —While using 60 lifetime reserve days —Once lifetime reserve days are used: —Additional 365

emergency (up to plan limits) | ✔ | ✔ | ✔ | ✔ | ✔ | ✔

Out-of-pocket limit in [2019] 2 | $5,560 2 | $2,7802

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61st thru 90th day 91st day and after: —While using 60 lifetime reserve days —Once lifetime reserve days are used: —Additional 365 days —Beyond the additional 365 days | All but $[1364] All but $[341] a day All but $[682] a day $0 $0 | $0 $[341] a day $[682] a day 100% of Medicare eligible expenses $0 | $[1364](Part A deductible) $0 $0 $0** All costs

SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility Within 30 days after leaving the hospital First 20 days 21 st thru 100th day 101 st day and after | All approved amounts All but $[170.50] a day $0 | $0 $0 $0 | $0 Up to $[170.50] a day All costs

BLOOD First 3 pints Additional amounts | $0 100% | 3 pints $0 | $0 $0

HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness. | All but very limited co-payment/ coinsurance for out-patient drugs and inpatient respite care | Medicare co-payment/ coinsurance | $0

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY

MEDICAL EXPENSES— IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | $0 Generally 80% | $0 Generally 20% | $[185] (Part B deductible) $0

Part B Excess Charges (Above Medicare Approved Amounts) | $0 | $0 | All costs

BLOOD First 3 pints Next $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | $0 $0 80% | All costs $0 20% | $0 $[185] (Part B deductible) $0

CLINICAL LABORATORY SERVICES— TESTS FOR DIAGNOSTIC S

der of Medicare Approved Amounts | $0 Generally 80% | $0 Generally 20% | $[185] (Part B deductible) $0

Part B Excess Charges (Above Medicare Approved Amounts) | $0 | $0 | All costs

BLOOD First 3 pints Next $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | $0 $0 80% | All costs $0 20% | $0 $[185] (Part B deductible) $0

CLINICAL LABORATORY SERVICES— TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY

HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies —Durable medical equipment First $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | 100% $0 80% | $0 $0 20% | $0 $[185] (Part B deductible) $0

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61 st thru 90th day 91 st day and after: —While using 60 lifetime reserve days —Once lifetime reserve days are used: —Additional 365 days —Beyond the additional 365 days | All but $[1364] All but $[341] a day All but $[682] a day $0 $0 | $[1364](Part A deductible) $[341] a day $[682] a day 100% of Medicare eligible expenses $0 | $0 $0 $0 $0** All costs

SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days 21 st thru 100 th day 101st day and after | All approved amounts All but $[170.50] a day $0 | $0 $0 $0 | $0 Up to $[170.50] a day All costs

BLOOD First 3 pints Additional amounts | $0 100% | 3 pints $0 | $0 $0

HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness | All but very limited co-payment/ coinsurance for out-patient drugs and inpatient respite care | Medicare co-payment/ coinsurance | $0

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY

MEDICAL EXPENSES— IN OR OUT OF THE HOSPITAL AND OUTPATIENT

Additional amounts | $0 100% | 3 pints $0 | $0 $0

HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness | All but very limited co-payment/ coinsurance for out-patient drugs and inpatient respite care | Medicare co-payment/ coinsurance | $0

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY

MEDICAL EXPENSES— IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | $0 Generally 80% | $0 Generally 20% | $[185] (Part B deductible) $0

Part B Excess Charges (Above Medicare Approved Amounts) | $0 | $0 | All costs

BLOOD First 3 pints Next $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | $0 $0 80% | All costs $0 20% | $0 $[185] (Part B deductible) $0

CLINICAL LABORATORY SERVICES— TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY

HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies —Durable medical equipment First $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | 100% $0 80% | $0 $0 20% | $0 $[185] (Part B deductible) $0

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61 st thru 90th day 91 st day and after: —While using 60 lifetime reserve days —Once lifetime reserve days are used: Additional 365 days —Beyond the additional 365 days | All but $[1364] All but $[341] a day All but $[682] a day $0 $0 | $[1364](Part A deductible) $[341] a day $[682] a day 100% of Medicare eligible expenses $0 | $0 $0 $0 $0** All costs

SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Me

serve days are used: Additional 365 days —Beyond the additional 365 days | All but $[1364] All but $[341] a day All but $[682] a day $0 $0 | $[1364](Part A deductible) $[341] a day $[682] a day 100% of Medicare eligible expenses $0 | $0 $0 $0 $0** All costs

SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days 21 st thru 100th day 101st day and after | All approved amounts All but $[170.50] a day $0 | $0 Up to $[170.50] a day $0 | $0 $0 All costs

BLOOD First 3 pints Additional amounts | $0 100% | 3 pints $0 | $0 $0

HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness. | All but very limited co-payment/ coinsurance for out-patient drugs and inpatient respite care | Medicare co-payment/ coinsurance | $0

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY

MEDICAL EXPENSES— IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | $0 Generally 80% | $[185] (Part B deductible) Generally 20% | $0 $0

Part B Excess Charges (Above Medicare Approved Amounts) | $0 | $0 | All costs

BLOOD First 3 pints Next $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | $0 $0 80% | All costs $[185] (Part B deductible) 20% | $0 $0 $0

CLINICAL LABORATORY SERVICES— TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY

HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies —Durable medical equipment First $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | 100% $0 80% | $0 $[185](Part B deductible) 20% | $0 $0 $0

SERVICES | MEDICAR

Y SERVICES— TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY

HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies —Durable medical equipment First $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | 100% $0 80% | $0 $[185](Part B deductible) 20% | $0 $0 $0

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY

FOREIGN TRAVEL— NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year Remainder of Charges | $0 $0 | $0 80% to a lifetime maxi-mum benefit of $50,000 | $250 20% and amounts over the $50,000 lifetime maximum

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61st thru 90th day 91st day and after: —While using 60 lifetime reserve days —Once lifetime reserve days are used: Additional 365 days —Beyond the additional 365 days | All but $[1364] All but $[341] a day All but $[682] a day $0 $0 | $[1364] (Part A deductible) $[341] a day $[682] a day 100% of Medicare eligible expenses $0 | $0 $0 $0 $0** All costs

SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days 21 st thru 100th day 101st day and after | All approved amounts All but $[170.50] a day $0 | $0 Up to $[170.50] a day $0 | $0 $0 All costs

BLOOD First 3 pints Additional amounts | $0 100% | 3 pints $0 | $0 $0

HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness | All but very limited co-payment/ coinsurance for out-patient drugs and inpatient respite care | Medicare co-payment/ coinsurance | $0

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY

MEDICAL EXPENSES— IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL

nal amounts | $0 100% | 3 pints $0 | $0 $0

HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness | All but very limited co-payment/ coinsurance for out-patient drugs and inpatient respite care | Medicare co-payment/ coinsurance | $0

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY

MEDICAL EXPENSES— IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | $0 Generally 80% | $0 Generally 20% | $[185] (Part B deductible) $0

Part B Excess Charges (Above Medicare Approved Amounts) | $0 | $0 | All costs

BLOOD First 3 pints Next $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | $0 $0 80% | All costs $0 20% | $0 $[185] (Part B deductible) $0

CLINICAL LABORATORY SERVICES— TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY

HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies — Durable medical equipment First $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | 100% $0 80% | $0 $0 20% | $0 $[185] (Part B deductible) $0

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY

FOREIGN TRAVEL—NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year Remainder of charges | $0 $0 | $0 80% to a lifetime maxi-mum benefit of $50,000 | $250 20% and amounts over the $50,000 lifetime maximum

A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row

outside the USA First $250 each calendar year Remainder of charges | $0 $0 | $0 80% to a lifetime maxi-mum benefit of $50,000 | $250 20% and amounts over the $50,000 lifetime maximum

A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

SERVICES | MEDICARE PAYS | [AFTER YOU PAY $2300 DEDUCTIBLE,**] PLAN PAYS | [IN ADDITION TO $2300 DEDUCTIBLE,**] YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61st thru 90 th day 91st day and after: —While using 60 Lifetime reserve days Once lifetime reserve days are used: —Additional 365 days Beyond the additional 365 days | All but $[1364] All but $[341] a day All but $[682] a day $0 $0 | $[1364] (Part A deductible) $[341] a day $[682] a day 100% of Medicare eligible expenses $0 | $0 $0 $0 $0*** All costs

SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days 21st thru 100th day 101 st day and after | All approved amounts All but $[170.50] a day $0 | $0 Up to $[170.50] a day $0 | $0 $0 All costs

BLOOD First 3 pints Additional amounts | $0 100% | 3 pints $0 | $0 $0

HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness

a Medicare-approved facility within 30 days after leaving the hospital First 20 days 21st thru 100th day 101 st day and after | All approved amounts All but $[170.50] a day $0 | $0 Up to $[170.50] a day $0 | $0 $0 All costs

BLOOD First 3 pints Additional amounts | $0 100% | 3 pints $0 | $0 $0

HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness. | All but very limited co-payment/ coinsurance for out-patient drugs and inpatient respite care | Medicare co-payment/coinsurance | $0

SERVICES | MEDICARE PAYS | [AFTER YOU PAY $2300 DEDUCTIBLE,**] PLAN PAYS | [IN ADDITION TO $2300 DEDUCTIBLE,**] YOU PAY

MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s Services, inpatient and Outpatient medical and Surgical services and Supplies, physical and Speech therapy, Diagnostic tests, Durable medical Equipment, First $[185] of Medicare Approved amounts* Remainder of Medicare Approved amounts | $0 Generally 80% | $[185] (Part B deductible) Generally 20% | $0 $0

Part B excess charges (Above Medicare Approved Amounts) | $0 | 100% | $0

BLOOD First 3 pints Next $[185] of Medicare Approved amounts* Remainder of Medicare Approved amounts | $0 $0 80% | All costs $[185] (Part B deductible) 20% | $0 $0 $0

CLINICAL LABORATORY SERVICES — -TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0

SERVICES | MEDICARE PAYS | AFTER YOU PAY $[2300] DEDUCTIBLE,** PLAN PAYS | IN ADDITION TO $[2300] DEDUCTIBLE,** YOU PAY

HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies —Durable medical equipment First $[185] of Medicare Approved Amounts* Remainder of Medicare — Approved Amounts | 100% $0 80% | $0 $[185] (Part B deductible) 20% | $0 $0 $0

SERVICES | MEDICARE PAYS | AFTER YOU PAY [$2300] DEDUCTIBLE,** PLAN PAYS | IN ADDITION TO $[2300] DEDUCTIBLE,** YOU PAY

FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically necessary Emergency care services Beginning during the first 60 days of each trip outside the USA

of Medicare Approved Amounts* Remainder of Medicare — Approved Amounts | 100% $0 80% | $0 $[185] (Part B deductible) 20% | $0 $0 $0

SERVICES | MEDICARE PAYS | AFTER YOU PAY [$2300] DEDUCTIBLE,** PLAN PAYS | IN ADDITION TO $[2300] DEDUCTIBLE,** YOU PAY

FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically necessary Emergency care services Beginning during the first 60 days of each trip outside the USA First $250 each calendar year Remainder of charges | $0 $0 | $0 80% to a lifetime maximum benefit of $50,000 | $250 20% and amounts over the $50,000 lifetime maximum

SERVICES | MEDICARE PAYS | AFTER YOU PAY $[2300] DEDUCTIBLE,** PLAN PAYS | IN ADDITION TO $[2300] DEDUCTIBLE,** YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61st thru 90th day 91st day and after: —While using 60 lifetime reserve days —Once lifetime reserve days are used: —Additional 365 days —Beyond the additional 365 days | All but $[1364] All but $[341] a day All but $[682] a day $0 $0 | $[1364] (Part A deductible) $[341] a day $[682] a day 100% of Medicare eligible expenses $0 | $0 $0 $0 $0*** All costs

SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days 21 st thru 100th day 101st day and after | All approved amounts All but $[170.50] a day $0 | $0 Up to $[170.50] a day $0 | $0 $0 All costs

BLOOD First 3 pints Additional amounts | $0 100% | 3 pints $0 | $0 $0

HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness | All but very limited co-payment/ coinsurance for out-patient drugs and inpatient respite care | Medicare co-payment/ coinsurance | $0

SERVICES | MEDICARE PAYS | AFTER YOU PAY $[2300] DEDUCTIBLE,** PLAN PAYS | IN ADDITION TO $[2300] DEDUCTIBLE,** YOU PAY

MEDICAL EXPENSES —IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician

ng a doctor's certification of terminal illness | All but very limited co-payment/ coinsurance for out-patient drugs and inpatient respite care | Medicare co-payment/ coinsurance | $0

SERVICES | MEDICARE PAYS | AFTER YOU PAY $[2300] DEDUCTIBLE,** PLAN PAYS | IN ADDITION TO $[2300] DEDUCTIBLE,** YOU PAY

MEDICAL EXPENSES —IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $[185] of Medicare Approved amounts* Remainder of Medicare Approved amounts | $0 Generally 80% | $0 Generally 20% | [$185] (Unless Part B deductible has been met) $0

Part B Excess c Charges (Above Medicare Approved Amounts) | $0 | 100% | $0

BLOOD First 3 pints Next $[185] of Medicare Approved amounts* Remainder of Medicare Approved amounts | $0 $0 80% | All costs $0 20% | $0 [$185] (Unless Part B deductible has been met) $0

SERVICES | MEDICARE PAYS | AFTER YOU PAY $[2300] DEDUCTIBLE,* * PLAN PAYS | IN ADDITION TO $[2300] DEDUCTIBLE,** YOU PAY

CLINICAL LABORATORY SERVICES— TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0

SERVICES | MEDICARE PAYS | AFTER YOU PAY $[2300] DEDUCTIBLE,** PLAN PAYS | IN ADDITION TO $[2300] DEDUCTIBLE,** YOU PAY

HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment First $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | 100% $0 80% | $0 $0 20% | $0 [$185] (Unless Part B deductible has been met) $0

SERVICES | MEDICARE PAYS | AFTER YOU PAY $[2300] DEDUCTIBLE,** PLAN PAYS | IN ADDITION TO $[2300] DEDUCTIBLE,** YOU PAY

FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically necessary Emergency care services Beginning during the first 60 days of each trip outside the USA First $250 each calendar year Remainder of charges | $0 $0 | $0 80% to a lifetime maximum benefit of $50,000 | $250 20% and amounts over the $50,000 lifetime maximum

SERVICES |

00] DEDUCTIBLE,** PLAN PAYS | IN ADDITION TO $[2300] DEDUCTIBLE,** YOU PAY

FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically necessary Emergency care services Beginning during the first 60 days of each trip outside the USA First $250 each calendar year Remainder of charges | $0 $0 | $0 80% to a lifetime maximum benefit of $50,000 | $250 20% and amounts over the $50,000 lifetime maximum

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY*

HOSPITALIZATION** Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61 st thru 90th day 91st day and after: —While using 60 lifetime reserve days —Once lifetime reserve days are used: —Additional 365 days —Beyond the additional 365 days | All but $[1364] All but $[341] a day All but $[682] a day $0 $0 | $[682](50% of Part A deductible) $[341] a day $[682] a day 100% of Medicare eligible expenses $0 | $[682] (50% of Part A deductible) ♦ $0 $0 $0*** All costs

SKILLED NURSING FACILITY CARE** You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility Within 30 days after leaving the hospital First 20 days 21 st thru 100th day 101st day and after | All approved amounts. All but $[170.50] a day $0 | $0 Up to $[85.25] a day (50% of Part A coinsurance) $0 | $0 Up to $[85.25] a day (50% of Part A coinsurance) ♦ All costs

BLOOD First 3 pints Additional amounts | $0 100% | 50% $0 | 50% ♦ $0

HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness

t 20 days 21 st thru 100th day 101st day and after | All approved amounts. All but $[170.50] a day $0 | $0 Up to $[85.25] a day (50% of Part A coinsurance) $0 | $0 Up to $[85.25] a day (50% of Part A coinsurance) ♦ All costs

BLOOD First 3 pints Additional amounts | $0 100% | 50% $0 | 50% ♦ $0

HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness. | All but very limited co-payment/ coinsurance for outpatient drugs and inpatient respite care | 50% of co-payment/ coinsurance | 50% of Medicare co-payment/coinsurance ♦

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY*

MEDICAL EXPENSES— IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $[185] of Medicare Approved Amounts**** Preventive Benefits for Medicare covered services Remainder of Medicare Approved Amounts | $0 Generally 75% or more of Medicare approved amounts Generally 80% | $0 Remainder of Medicare approved amounts Generally 10% | $[185] (Part B deductible)**** ♦ All costs above Medicare approved amounts Generally 10% ♦

Part B Excess Charges (Above Medicare Approved Amounts) | $0 | $0 | All costs (and they do not count toward annual out-of-pocket limit of [$5560])*

BLOOD First 3 pints Next $[185] of Medicare Approved Amounts**** Remainder of Medicare Approved Amounts | $0 $0 Generally 80% | 50% $0 Generally 10% | 50% ♦ $[185] (Part B deductible)**** ♦ Generally 10% ♦

CLINICAL LABORATORY SERVICES— TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY*

HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies —Durable medical equipment First $[185] of Medicare Approved Amounts***** Remainder of Medicare Approved Amounts | 100% $0 80% | $0 $0 10% | $0 $[185] (Part B deductible) ♦ 10% ♦

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY*

HOSPIT

% | $0 | $0

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY*

HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies —Durable medical equipment First $[185] of Medicare Approved Amounts***** Remainder of Medicare Approved Amounts | 100% $0 80% | $0 $0 10% | $0 $[185] (Part B deductible) ♦ 10% ♦

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY*

HOSPITALIZATION** Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61st thru 90th day 91st day and after: —While using 60 lifetime reserve days —Once lifetime reserve days are used: —Additional 365 days —Beyond the additional 365 days | All but $[1364] All but $[341] a day All but $[682] a day $0 $0 | $[1023] (75% of Part A deductible) $[341] a day $[682] a day 100% of Medicare eligible expenses $0 | $[341] (25% of Part A deductible) ♦ $0 $0 $0*** All costs

SKILLED NURSING FACILITY CARE** You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility Within 30 days after leaving the hospital First 20 days 21 st thru 100th day 101st day and after | All approved amounts All but $[170.50] a day $0 | $0 Up to $[127.88] a day [(75% of Part A Coinsurance) $0 | $0 Up to $[42.63] a day (25% of Part A Coinsurance) ♦ All costs

BLOOD First 3 pints Additional amounts | $0 100% | 75% $0 | 25% ♦ $0

HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness

20 days 21 st thru 100th day 101st day and after | All approved amounts All but $[170.50] a day $0 | $0 Up to $[127.88] a day [(75% of Part A Coinsurance) $0 | $0 Up to $[42.63] a day (25% of Part A Coinsurance) ♦ All costs

BLOOD First 3 pints Additional amounts | $0 100% | 75% $0 | 25% ♦ $0

HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness. | All but very limited co-payment/ coinsurance for outpatient drugs and inpatient respite care | 75% of co-payment/ coinsurance | 25% of co-payment/ coinsurance ♦

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY*

MEDICAL EXPENSES— IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physi-cian’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $[185] of Medicare Approved Amounts**** Preventive Benefits for Medicare covered services Remainder of Medicare Approved Amounts | $0 Generally 80% or more of Medicare approved amounts Generally 80% | $0 Remainder of Medicare approved amounts Generally 15% | $[185] (Part B deductible)**** ♦ All costs above Medicare approved amounts Generally 5% ♦

Part B Excess Charges (Above Medicare Approved Amounts) | $0 | $0 | All costs (and they do not count toward annual out-of-pocket limit of [$2780])*

BLOOD First 3 pints Next $[185] of Medicare Approved Amounts**** Remainder of Medicare Approved Amounts | $0 $0 Generally 80% | 75% $0 Generally 15% | 25% ♦ $[185] (Part B deductible) ♦ Generally 5% ♦

CLINICAL LABORATORY SERVICES— TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY*

HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies —Durable medical equipment First $[185] of Medicare Approved Amounts***** Remainder of Medicare Approved Amounts | 100% $0 80% | $0 $0 15% | $0 $[185] (Part B deductible) ♦ 5% ♦

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY

HOSPITALIZATION* Semi

ERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY*

HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies —Durable medical equipment First $[185] of Medicare Approved Amounts***** Remainder of Medicare Approved Amounts | 100% $0 80% | $0 $0 15% | $0 $[185] (Part B deductible) ♦ 5% ♦

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61 st thru 90th day 91 st day and after: —While using 60 lifetime reserve days —Once lifetime reserve days are used: —Additional 365 days —Beyond the additional 365 days | All but $[1364] All but $[341] a day All but $[682] a day $0 $0 | $[682] (50% of Part A deductible) $[341] a day $[682] a day 100% of Medicare eligible expenses $0 | $[682] (50% of Part A deductible) $0 $0 $0** All costs

SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days 21 st thru 100th day 101st day and after | All approved amounts All but $[170.50] a day $0 | $0 Up to $[170.50] a day $0 | $0 $0 All costs

BLOOD First 3 pints Additional amounts | $0 100% | 3 pints $0 | $0 $0

HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness | All but very limited co-payment/ coinsurance for outpatient drugs and inpatient respite care | Medicare co-payment/ coinsurance | $0

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY

MEDICAL EXPENSES— IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment —First $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | $0 Generally 80% | $0 Generally 20% | $[185] (Part B deductible) $0

Part B Excess Charges (Above Medicar

TAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment —First $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | $0 Generally 80% | $0 Generally 20% | $[185] (Part B deductible) $0

Part B Excess Charges (Above Medicare Approved Amounts) | $0 | $0 | All costs

BLOOD First 3 pints Next $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | $0 $0 80% | All costs $0 20% | $0 $[185] (Part B deductible) $0

CLINICAL LABORATORY SERVICES— TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY

HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies —Durable medical equipment First $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | 100% $0 80% | $0 $0 20% | $0 $[185](PartB deductible) $0

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY

FOREIGN TRAVEL— NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year Remainder of Charges | $0 $0 | $0 80% to a lifetime maxi-mum benefit of $50,000 | $250 20% and amounts over the $50,000 lifetime maximum

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61 st thru 90th day 91 st day and after: —While using 60 lifetime reserve days —Once lifetime reserve days are used: —Additional 365 days —Beyond the additional 365 days | All but $[1364] All but $[341] a day All but $[682] a day $0 $0 | $[1364] (Part A deductible) $[341] a day $[682] a day 100% of Medicare eligible expenses $0 | $0 $0 $0 $0** All costs

SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved fa

—Additional 365 days —Beyond the additional 365 days | All but $[1364] All but $[341] a day All but $[682] a day $0 $0 | $[1364] (Part A deductible) $[341] a day $[682] a day 100% of Medicare eligible expenses $0 | $0 $0 $0 $0** All costs

SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days 21 st thru 100th day 101st day and after | All approved amounts All but $[170.50] a day $0 | $0 Up to $[170.50] a day $0 | $0 $0 All costs

BLOOD First 3 pints Additional amounts | $0 100% | 3 pints $0 | $0 $0

HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness | All but very limited co-payment/ coinsurance for outpatient drugs and inpatient respite care | Medicare co-payment/ coinsurance | $0

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY

MEDICAL EXPENSES— IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | $0 Generally 80% | $0 Balance, other than up to [$20] per office visit and up to [$50] per emergency room visit. The co-payment of up to [$50] is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense. | $[185] (Part B deductible) Up to [$20] per office visit and up to [$50] per emergency room visit. The co-payment of up to [$50] is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense

isit. The co-payment of up to [$50] is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense. | $[185] (Part B deductible) Up to [$20] per office visit and up to [$50] per emergency room visit. The co-payment of up to [$50] is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.

Part B Excess Charges (Above Medicare Approved Amounts) | $0 | $0 | All costs

BLOOD First 3 pints Next $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | $0 $0 80% | All costs $0 20% | $0 $[185] (Part B deductible) $0

CLINICAL LABORATORY SERVICES— TESTS FOR DIAGNOSTIC SERVICES | 100% | $0 | $0

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY

HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies —Durable medical equipment First $[185] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts | 100% $0 80% | $0 $0 20% | $0 $[185] (Part B deductible) $0

SERVICES | MEDICARE PAYS | PLAN PAYS | YOU PAY

FOREIGN TRAVEL— NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year Remainder of Charges | $0 $0 | $0 80% to a lifetime maximum benefit of $50,000 | $250 20% and amounts over the $50,000 lifetime maximum

Rules for, or determination of, eligibility (including enrollment and continued eligibility) for benefits under the policy;

The computation of premium or contribution amounts under the policy;

The application of any pre-existing condition exclusion under the policy; and

Other activities related to the creation, renewal, or replacement of a contract of health insurance or health benefits.

Line | (a) Earned Premium 3 | (b) Incurred Claims 4

1. | Current Year’s Experience

a. Total (all policy years)

b. Current year’s issues 5

c. Net (for reporting purposes = 1a–1b

2. | Past Years’ Experience (all policy years)

3

pre-existing condition exclusion under the policy; and

Other activities related to the creation, renewal, or replacement of a contract of health insurance or health benefits.

Line | (a) Earned Premium 3 | (b) Incurred Claims 4

1. | Current Year’s Experience

a. Total (all policy years)

b. Current year’s issues 5

c. Net (for reporting purposes = 1a–1b

2. | Past Years’ Experience (all policy years)

3. | Total Experience (Net Current Year + Past Year)

4. | Refunds Last Year (Excluding Interest)

5. | Previous Since Inception (Excluding Interest)

6. | Refunds Since Inception (Excluding Interest)

7. | Benchmark Ratio Since Inception ( see worksheet for Ratio 1 )

8. | Experienced Ratio Since Inception ( Ratio 2 ) Total Actual Incurred Claims (line 3, col. b) Total Earned Prem. (line 3, col. a)–Refunds Since Inception (line 6)

9. | Life Years Exposed Since Inception If the Experienced Ratio is less than the Benchmark Ratio, and there are more than 500 life years exposure, then proceed to calculation of refund.

10. | Tolerance Permitted (obtained from credibility table)

Life Years Exposed

Since Inception | Tolerance

10,000 + | 0.0%

5,000 -9,999 | 5.0%

2,500 -4,999 | 7.5%

1,000 -2,499 | 10.0%

500 - 999 | 15.0%

If less than 500, no credibility.

11. | Adjustment to Incurred Claims for Credibility

Ratio 3 = Ratio 2 + Tolerance

12. | Adjusted Incurred Claims

[Total Earned Premiums (line 3, col. a)–Refunds Since Inception (line 6)] x Ratio 3 (line 11)

13. | Refund =

Total Earned Premiums (line 3, col. a)–Refunds Since Inception (line 6) –[Adjusted Incurred Claims (line 12)/Benchmark Ratio (Ratio 1)]

| 15.0%

If less than 500, no credibility.

11. | Adjustment to Incurred Claims for Credibility

Ratio 3 = Ratio 2 + Tolerance

12. | Adjusted Incurred Claims

[Total Earned Premiums (line 3, col. a)–Refunds Since Inception (line 6)] x Ratio 3 (line 11)

13. | Refund =

Total Earned Premiums (line 3, col. a)–Refunds Since Inception (line 6) –[Adjusted Incurred Claims (line 12)/Benchmark Ratio (Ratio 1)]

(a) | (b) 4 | (c) | (d) | (e) | (f) | (g) | (h) | (i) | (j) | (o) 5

Earned | Cumulative | Cumulative | Policy Year

Year | Premium | Factor | (b)x(c) | Loss Ratio | (d)x(e) | Factor | (b)x(g) | Loss Ratio | (h)x(i) | Loss Ratio

1 | 2.770 | 0.507 | 0.000 | 0.000 | 0.46

2 | 4.175 | 0.567 | 0.000 | 0.000 | 0.63

3 | 4.175 | 0.567 | 1.194 | 0.759 | 0.75

4 | 4.175 | 0.567 | 2.245 | 0.771 | 0.77

5 | 4.175 | 0.567 | 3.170 | 0.782 | 0.80

6 | 4.175 | 0.567 | 3.998 | 0.792 | 0.82

7 | 4.175 | 0.567 | 4.754 | 0.802 | 0.84

8 | 4.175 | 0.567 | 5.445 | 0.811 | 0.87

9 | 4.175 | 0.567 | 6.075 | 0.818 | 0.88

10 | 4.175 | 0.567 | 6.650 | 0.824 | 0.88

11 | 4.175 | 0.567 | 7.176 | 0.828 | 0.88

12 | 4.175 | 0.567 | 7.655 | 0.831 | 0.88

13 | 4.175 | 0.567 | 8.093 | 0.834 | 0.89

14 | 4.175 | 0.567 | 8.493 | 0.837 | 0.89

15+ 6 | 4.175 | 0.567 | 8.684 | 0.838 | 0.89

Total: | (k): | (l): | (m): | (n):

(a) | (b) 4 | (c) | (d) | (e) | (f) | (g) | (h) | (i) | (j) | (o) 5

Earned | Cumulative | Cumulative | Policy Year

Year | Premium | Factor | (b)x(c) | Loss Ratio | (d)x(e) | Factor | (b)x(g) | Loss Ratio | (h)x(i) | Loss Ratio

1 | 2.770 | 0.442 | 0.000 | 0.000 | 0.40

2 | 4.175 | 0.493 | 0.000 | 0.000 | 0.55

3 | 4.175 | 0.493 | 1.194 | 0.659 | 0.65

4 | 4.175 | 0.493 | 2.245 | 0.669 | 0.67

5 | 4.175 | 0.493 | 3.170 | 0.678 | 0.69

6 | 4.175 | 0.493 | 3.998 | 0.686 | 0.71

7 | 4.175 | 0.493 | 4.754 | 0.695 | 0.73

8 | 4.175 | 0.493 | 5.445 | 0.702 | 0.75

9 | 4.175 | 0.493 | 6.075 | 0.708 | 0.76

10 | 4.175 | 0.493 | 6.650 | 0.713 | 0.76

11 | 4.175 | 0.493 | 7.176 | 0.717 | 0.76

12 | 4.175 | 0.493 | 7.655 | 0.720 | 0.77

13 | 4.175 | 0.493 | 8.093 | 0.723 | 0.

0.493 | 2.245 | 0.669 | 0.67

5 | 4.175 | 0.493 | 3.170 | 0.678 | 0.69

6 | 4.175 | 0.493 | 3.998 | 0.686 | 0.71

7 | 4.175 | 0.493 | 4.754 | 0.695 | 0.73

8 | 4.175 | 0.493 | 5.445 | 0.702 | 0.75

9 | 4.175 | 0.493 | 6.075 | 0.708 | 0.76

10 | 4.175 | 0.493 | 6.650 | 0.713 | 0.76

11 | 4.175 | 0.493 | 7.176 | 0.717 | 0.76

12 | 4.175 | 0.493 | 7.655 | 0.720 | 0.77

13 | 4.175 | 0.493 | 8.093 | 0.723 | 0.77

14 | 4.175 | 0.493 | 8.493 | 0.725 | 0.77

15+ 6 | 4.175 | 0.493 | 8.684 | 0.725 | 0.77

Total: | (k): | (l): | (m): | (n):

hospital or medical expenses up to the maximum stated in the policy

hospitalization

physician services

[ outpatient prescription drugs if you are enrolled in Medicare Part D]

other approved items and services

any of the services covered by the policy are also covered by Medicare

hospitalization

physician services

[outpatient prescription drugs if you are enrolled in Medicare Part D]

other approved items and services

hospital or medical expenses up to the maximum stated in the policy

hospitalization

physician services

hospice

[outpatient prescription drugs if you are enrolled in Medicare Part D]

other approved items and services

hospitalization

physician services

hospice

[outpatient prescription drugs if you are enrolled in Medicare Part D]

other approved items and services

any expenses or services covered by the policy are also covered by Medicare

hospitalization

physician services

[outpatient prescription drugs if you are enrolled in Medicare Part D]

hospice

other approved items and services

any expenses or services covered by the policy are also covered by Medicare; or

it pays the fixed dollar amount stated in the policy and Medicare covers the same event

hospitalization

physician services

hospice care

[outpatient prescription drugs if you are enrolled in Medicare Part D]

other approved items & services

the benefits stated in the policy and coverage for the same event is provided by Medicare

hospitalization

physician services

hospice

[outpatient prescription drugs if you are enrolled in Medicare

ted in the policy and Medicare covers the same event

hospitalization

physician services

hospice care

[outpatient prescription drugs if you are enrolled in Medicare Part D]

other approved items & services

the benefits stated in the policy and coverage for the same event is provided by Medicare

hospitalization

physician services

hospice

[outpatient prescription drugs if you are enrolled in Medicare Part D]

other approved items and services

hospitalization

physician services

[outpatient prescription drugs if you are enrolled in Medicare Part D]

other approved items and services

hospitalization

physician services

[outpatient prescription drugs if you are enrolled in Medicare Part D]

other approved items and services

hospitalization

physician services

hospice

[outpatient prescription drugs if you are enrolled in Medicare Part D]

other approved items and services

hospitalization

physician services

hospice

[outpatient prescription drugs if you are enrolled in Medicare Part D]

other approved items and services

hospitalization

physician services

hospice

[ outpatient prescription drugs if you are enrolled in Medicare Part D]

other approved items and services

hospitalization

physician services

hospice care

[outpatient prescription drugs if you are enrolled in Medicare Part D]

other approved items & services

hospitalization

physician services

hospice

[outpatient prescription drugs if you are enrolled in Medicare Part D]

other approved items and services

1.0 Purpose

The purpose of this regulation is to provide for the reasonable standardization of coverage and simplification of terms and benefits of Medicare supplement policies; to facilitate public understanding and comparison of such policies; to eliminate provisions contained in such policies which may be misleading or confusing in connection with the purchase of such policies or with the settlement of claims; and to provide for full disclosures in the sale of accident and sickness insurance coverages to persons eligible for Medicare

ts of Medicare supplement policies; to facilitate public understanding and comparison of such policies; to eliminate provisions contained in such policies which may be misleading or confusing in connection with the purchase of such policies or with the settlement of claims; and to provide for full disclosures in the sale of accident and sickness insurance coverages to persons eligible for Medicare.

2.0 Authority

This regulation is issued pursuant to the authority vested in the Commissioner under 18 Del.C. §§311 and 3403.

3.0 Applicability and Scope

3.1 Except as otherwise specifically provided in Sections 7.0, 16.0, 17.0, 20.0, and 25.0, this regulation shall apply to:

3.1.1 All Medicare supplement policies delivered or issued for delivery in this State on or after the effective date of this regulation; and

3.1.2 All certificates issued under group Medicare supplement policies, which certificates have been delivered or issued for delivery in this state.

3.2 This regulation shall not apply to a policy or contract of one or more employers or labor organizations, or of the trustees of a fund established by one or more employers or labor organizations, or combination thereof, for employees or former employees, or a combination thereof, or for members or former members, or a combination thereof, of the labor organizations.

22 DE Reg. 1026 (06/01/19)

4.0 Definitions

For purposes of this regulation:

“ Applicant ” means:

“ Bankruptcy ” means when a Medicare Advantage organization that is not an issuer has filed, or has had filed against it, a petition for declaration of bankruptcy and has ceased doing business in the state.

“ Certificate ” means any certificate delivered or issued for delivery in this state under a group Medicare supplement policy.

“ Certificate form ” means the form on which the certificate is delivered or issued for delivery by the issuer

ge organization that is not an issuer has filed, or has had filed against it, a petition for declaration of bankruptcy and has ceased doing business in the state.

“ Certificate ” means any certificate delivered or issued for delivery in this state under a group Medicare supplement policy.

“ Certificate form ” means the form on which the certificate is delivered or issued for delivery by the issuer.

“ Continuous period of creditable coverage ” means the period during which an individual was covered by creditable coverage, if during the period of the coverage the individual had no breaks in coverage greater than sixty-three (63) days.

“ Creditable coverage ” means, with respect to an individual, coverage of the individual provided under any of the following:

A group health plan;

“ Creditable coverage ” shall not include one or more, or any combination of, the following:

“ Creditable coverage ” shall not include the following benefits if they are provided under a separate policy, certificate or contract of insurance or are otherwise not an integral part of the plan:

“ Creditable coverage ” shall not include the following benefits if offered as independent, non-coordinated benefits:

“ Creditable coverage ” shall not include the following if it is offered as a separate policy, certificate or contract of insurance:

“ Employee welfare benefit plan ” means a plan, fund or program of employee benefits as defined in 29 U.S.C. Section 1002 (Employee Retirement Income Security Act).

“ Insolvency ” means when an issuer, licensed to transact the business of insurance in this state, has had a final order of liquidation entered against it with a finding of insolvency by a court of competent jurisdiction in the issuer’s state of domicile.

“ Issuer ” includes insurance companies, fraternal benefit societies, health care service plans, health maintenance organizations, and any other entity delivering or issuing for delivery in this state Medicare supplement policies or certificates

s had a final order of liquidation entered against it with a finding of insolvency by a court of competent jurisdiction in the issuer’s state of domicile.

“ Issuer ” includes insurance companies, fraternal benefit societies, health care service plans, health maintenance organizations, and any other entity delivering or issuing for delivery in this state Medicare supplement policies or certificates.

“ Medicare ” means the “Health Insurance for the Aged Act,” Title XVIII of the Social Security Amendments of 1965, as then constituted or later amended.

“ Medicare Advantage plan ” means a plan of coverage for health benefits under Medicare Part C as defined in 42 U.S.C. 1395w‑28(b)(1), and includes:

“ Medicare supplement policy ” means a group or individual policy of accident and sickness insurance or a subscriber contract of hospital and medical service associations or health maintenance organizations, other than a policy issued pursuant to a contract under Section 1876 of the federal Social Security Act (42 U.S.C. § 1395 et. seq.) or an issued policy under a demonstration project specified in 42 U.S.C. § 1395ss(g)(1), which is advertised, marketed or designed primarily as a supplement to reimbursements under Medicare for the hospital, medical or surgical expenses of persons eligible for Medicare. “ Medicare supplement policy ” does not include Medicare Advantage plans established under Medicare Part C, Outpatient Prescription Drug plans established under Medicare Part D, or any Health Care Prepayment Plan (HCPP) that provides benefits pursuant to an agreement under the Social Security Act at 42 U.S.C. § 1833(a)(1)(A).

" Pre-Standardized Medicare supplement benefit plan ," " Pre-Standardized benefit plan " or " Pre-Standardized plan " means a group or individual policy of Medicare supplement insurance issued prior to January 1, 1992

tablished under Medicare Part D, or any Health Care Prepayment Plan (HCPP) that provides benefits pursuant to an agreement under the Social Security Act at 42 U.S.C. § 1833(a)(1)(A).

" Pre-Standardized Medicare supplement benefit plan ," " Pre-Standardized benefit plan " or " Pre-Standardized plan " means a group or individual policy of Medicare supplement insurance issued prior to January 1, 1992.

" 1990 Standardized Medicare supplement benefit plan ," " 1990 Standardized benefit plan " or " 1990 plan " means a group or individual policy of Medicare supplement insurance issued on or after January 1, 1992 and prior to June 1, 2010 and includes Medicare supplement insurance policies and certificates renewed on or after that date which are not replaced by the issuer at the request of the insured.

“ 2010 Standardized Medicare supplement benefit plan ," " 2010 Standardized benefit plan " or " 2010 plan " means a group or individual policy of Medicare supplement insurance issued with an effective date on or after June 1, 2010.

“ Policy form ” means the form on which the policy is delivered or issued for delivery by the issuer.

“ Secretary ” means the Secretary of the United States Department of Health and Human Services.

22 DE Reg. 1026 (06/01/19)

5.0 Policy Definitions and Terms

5.1 No policy or certificate may be advertised, solicited or issued for delivery in this state as a Medicare supplement policy or certificate unless the policy or certificate contains definitions or terms that conform to the requirements of this Section.

5.2 For purposes of Section 5.0, the following terms have the following meanings:

“ Accident ,” “ accidental injury ,” or “ accidental means ” shall be defined to employ “result” language and shall not include words that establish an accidental means test or use words such as “external, violent, visible wounds” or similar words of description or characterization.

“ Benefit period ” or “ Medicare Benefit Period ” shall not be defined more restrictively than as defined in the Medicare program

“ accidental injury ,” or “ accidental means ” shall be defined to employ “result” language and shall not include words that establish an accidental means test or use words such as “external, violent, visible wounds” or similar words of description or characterization.

“ Benefit period ” or “ Medicare Benefit Period ” shall not be defined more restrictively than as defined in the Medicare program.

“ Convalescent nursing home ,” “ extended care facility ,” or “ skilled nursing facility ” shall not be defined more restrictively than as defined in the Medicare program.

“ Health care expenses ” means, for purposes of Section 14.0, expenses of health maintenance organizations associated with the delivery of health care services, which expenses are analogous to incurred losses of insurers.

“ Hospital ” may be defined in relation to its status, facilities and available services or to reflect its accreditation by the Joint Commission on Accreditation of Hospitals, but not more restrictively than as defined in the Medicare program.

“ Medicare ” shall be defined in the policy and certificate. Medicare may be substantially defined as “The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as Then Constituted or Later Amended,” or “Title I, Part I of Public Law 89-97, as Enacted by the Eighty-Ninth Congress of the United States of America and popularly known as the Health Insurance for the Aged Act, as then constituted and any later amendments or substitutes thereof,” or words of similar import.

“ Medicare eligible expenses ” shall mean expenses of the kinds covered by Medicare Parts A and B, to the extent recognized as reasonable and medically necessary by Medicare.

“ Medicare program ” means the Federal program through which Medicare is administered.

“ Physician ” shall not be defined more restrictively than as defined in the Medicare program

itutes thereof,” or words of similar import.

“ Medicare eligible expenses ” shall mean expenses of the kinds covered by Medicare Parts A and B, to the extent recognized as reasonable and medically necessary by Medicare.

“ Medicare program ” means the Federal program through which Medicare is administered.

“ Physician ” shall not be defined more restrictively than as defined in the Medicare program.

“ Sickness ” shall not be defined to be more restrictive than the following: “Sickness means illness or disease of an insured person which first manifests itself after the effective date of insurance and while the insurance is in force.” The definition may be further modified to exclude sicknesses or diseases for which benefits are provided under any workers’ compensation, occupational disease, employer’s liability or similar law.

22 DE Reg. 1026 (06/01/19)

6.0 Policy Provisions

6.1 Except for permitted preexisting condition clauses as described in subsections 7.1.1, 8.1.1 and 9.1.1 of this regulation, no policy or certificate may be advertised, solicited or issued for delivery in this State as a Medicare supplement policy if the policy or certificate contains limitations or exclusions on coverage that are more restrictive than those of Medicare.

6.2 No Medicare supplement policy or certificate may use waivers to exclude, limit or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions.

6.3 No Medicare supplement policy or certificate in force in the State shall contain benefits that duplicate benefits provided by Medicare.

6.4 Issuance and Renewal

6.4.1 Subject to subsections 7.1.4, 7.1.5 and 7.1.7, and 8.1.4 and 8.1.5 of this regulation, a Medicare supplement policy with benefits for outpatient prescription drugs in existence prior to January 1, 2006 shall be renewed for current policyholders who do not enroll in Part D at the option of the policyholder

contain benefits that duplicate benefits provided by Medicare.

6.4 Issuance and Renewal

6.4.1 Subject to subsections 7.1.4, 7.1.5 and 7.1.7, and 8.1.4 and 8.1.5 of this regulation, a Medicare supplement policy with benefits for outpatient prescription drugs in existence prior to January 1, 2006 shall be renewed for current policyholders who do not enroll in Part D at the option of the policyholder.

6.4.2 A Medicare supplement policy with benefits for outpatient prescription drugs shall not be issued after December 31, 2005.

6.4.3 After December 31, 2005, a Medicare supplement policy with benefits for outpatient prescription drugs may not be renewed after the policyholder enrolls in Medicare Part D unless:

6.4.3.1 The policy is modified to eliminate outpatient prescription coverage for expenses of outpatient prescription drugs incurred after the effective date of the individual’s coverage under a Part D plan and;

6.4.3.2 Premiums are adjusted to reflect the elimination of outpatient prescription drug coverage at the time of Medicare Part D enrollment, accounting for any claims paid, if applicable.

22 DE Reg. 1026 (06/01/19)

7.0 Minimum Benefit Standards for Pre-Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery Prior to July 1, 2009.

7.1 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. The following general standards apply to Medicare supplement policies and certificates and are in addition to all other requirements of this regulation.

7.1.1 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

t inconsistent with these standards. The following general standards apply to Medicare supplement policies and certificates and are in addition to all other requirements of this regulation.

7.1.1 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.

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

7.1.3 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.

7.1.4 A “non-cancellable,” “guaranteed renewable,” or “non-cancellable and guaranteed renewable” Medicare supplement policy shall not:

7.1.4.1 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

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

7.1.5 Policy Termination or Cancelation

7.1.5.1 Except as authorized by the Commissioner, 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

d, other than the nonpayment of premium; or

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

7.1.5 Policy Termination or Cancelation

7.1.5.1 Except as authorized by the Commissioner, 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.

7.1.5.2 If a group Medicare supplement insurance policy is terminated by the group policyholder and not replaced as provided in subsection 7.1.5.4 of this regulation, the issuer shall offer certificate holders an individual Medicare supplement policy. The issuer shall offer the certificate holder at least the following choices:

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

7.1.5.2.2 An individual Medicare supplement policy which provides only such benefits as are required to meet the minimum standards as defined in subsection 9.2 of this regulation.

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

7.1.5.3.1 Offer the certificate holder the conversion opportunities described in subsection 7.1.5.2 of this regulation; or

7.1.5.3.2 At the option of the group policyholder, offer the certificate holder continuation of coverage under the group policy.

7.1.5.4 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

t 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.

7.1.6 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.

7.1.7 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 subsection.

7.2 Minimum Benefit Standards.

7.2.1 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;

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

7.2.3 Coverage of Part A Medicare eligible expenses incurred as daily hospital charges during use of Medicare’s lifetime hospital inpatient reserve days;

7.2.4 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 365 days;

7.2.5 Coverage under Medicare Part A for the reasonable cost of the first th

time hospital inpatient reserve days;

7.2.4 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 365 days;

7.2.5 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 Part B;

7.2.6 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 a maximum calendar year out-of-pocket amount equal to the Medicare Part B deductible [$100];

7.2.7 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 Part A, subject to the Medicare deductible amount.

22 DE Reg. 1026 (06/01/19)

8.0 Benefit Standards for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued or Delivered on or After July 1, 2009 and with an effective date of coverage prior to June 1, 2010

8.1 The following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this state on or after July 1, 2009 and prior to 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 standards

e 1, 2010

8.1 The following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this state on or after July 1, 2009 and prior to 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 standards. The following general standards apply to Medicare supplement policies and certificates and are in addition to all other requirements of this regulation.

8.1.1 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 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 six (6) months before the effective date of coverage.

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

8.1.3 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.

8.1.4 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.

8.1.5 Each Medicare supplement policy shall be guaranteed renewable.

8.1.5.1 The issuer shall not cancel or non-renew the policy solely on the ground of health status of the individual

nt 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.

8.1.5 Each Medicare supplement policy shall be guaranteed renewable.

8.1.5.1 The issuer shall not cancel or non-renew the policy solely on the ground of health status of the individual.

8.1.5.2 The issuer shall not cancel or non-renew the policy for any reason other than nonpayment of premium or material misrepresentation.

8.1.5.3 If the Medicare supplement policy is terminated by the group policyholder and is not replaced as provided under subsection 8.1.5.5 of this regulation, the issuer shall offer certificate holders an individual Medicare supplement policy which (at the option of the certificate holder);

8.1.5.3.1 Provides for continuation of the benefits contained in the group policy, or

8.1.5.3.2 Provides for benefits that otherwise meet the requirements of this subsection.

8.1.5.4 If an individual is a certificate holder in a group Medicare supplement policy and the individual terminates membership in the group, the issuer shall:

8.1.5.4.1 Offer the certificate holder the conversion opportunity described in subsection 8.1.5.3 of this regulation, or

8.1.5.4.2 At the option of the group policyholder, offer the certificate holder continuation of coverage under the group policy.

8.1.5.5 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

plement 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.

8.1.5.6 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 subsection.

8.1.6 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.

8.1.7 Policy or Certificate Suspension

8.1.7.1 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

r 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.

8.1.7.2 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.

8.1.7.3 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.

8.1.7.4 Reinstitution of coverages as described in subsections 8.1.7.2 and 8.1.7.3 of this regulation:

8.1.7.4.1 Shall not provide for any waiting period with respect to treatment of preexisting conditions;

8.1.7.4.2 Shall provide for resumption of coverage that is substantially equivalent to coverage in effect before the date of suspension

erage within ninety (90) days after the date of the loss.

8.1.7.4 Reinstitution of coverages as described in subsections 8.1.7.2 and 8.1.7.3 of this regulation:

8.1.7.4.1 Shall not provide for any waiting period with respect to treatment of preexisting conditions;

8.1.7.4.2 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

8.1.7.4.3 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.

8.1.8 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 10.0 of this regulation) to a 2010 Standardized plan (as described in Section 11.0 of this regulation), the offer and subsequent exchange shall comply with the following requirements:

8.1.8.1 If 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

d 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.

8.1.8.2 The rating class of the new policy or certificate shall be the class closest to the insured’s class of the replaced coverage.

8.1.8.3 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 six (6) months to any added benefits contained in the new 2010 Standardized policy or certificate not contained in the exchanged policy.

8.1.8.4 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.

8.2 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

law.

8.2 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.

8.2.1 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;

8.2.2 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;

8.2.3 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;

8.2.4 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;

8.2.5 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;

8.3 Standards for Additional Benefits. The following additional benefits shall be included in Medicare Supplement Benefit Plans “B” through “J” only as provided by Section 11.0 of this regulation

epartment 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;

8.3 Standards for Additional Benefits. The following additional benefits shall be included in Medicare Supplement Benefit Plans “B” through “J” only as provided by Section 11.0 of this regulation.

8.3.1 Medicare Part A Deductible: Coverage for all of the Medicare Part A inpatient hospital deductible amount per benefit period.

8.3.2 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.

8.3.3 Medicare Part B Deductible: Coverage for all of the Medicare Part B deductible amount per calendar year regardless of hospital confinement.

8.3.4 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.

8.3.5 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.

8.3.6 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

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.

8.3.7 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.

8.3.8 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

een 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.

8.3.9 Preventive Medical Care Benefit:

8.3.9.1 Coverage for the following preventive health services not covered by Medicare:

8.3.9.1.1 An annual clinical preventive medical history and physical examination that may include tests and services from subsection 8.3.9.1.2 of this regulation and patient education to address preventive health care measures;

8.3.9.1.2 Preventive screening tests or preventive services, the selection and frequency of which is determined to be medically appropriate by the attending physician.

8.3.9.2 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.

8.3.10 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.

8.3.10.1 For purposes of this benefit, the following definitions shall apply:

8.3.10.1.1 “ 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

ties of daily living for those recovering from an illness, injury or surgery.

8.3.10.1 For purposes of this benefit, the following definitions shall apply:

8.3.10.1.1 “ 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.

8.3.10.1.2 “ 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.

8.3.10.1.3 “ At 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.

8.3.10.1.4 “ 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.

8.3.10.2 Coverage Requirements and Limitations.

8.3.10.2.1 At-home recovery services provided must be primarily services which assist in activities of daily living.

8.3.10.2.2 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.

8.3.10.3 Coverage described in subsection 8.3.10.2 of this regulation is limited to:

8.3.10.3.1 No more than the number and type of at-home recovery visits certified as necessary by the insured’s attending physician

an 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.

8.3.10.3 Coverage described in subsection 8.3.10.2 of this regulation is limited to:

8.3.10.3.1 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;

8.3.10.3.2 The actual charges for each visit up to a maximum reimbursement of $40 per visit;

8.3.10.3.3 $1,600 per calendar year;

8.3.10.3.4 Seven (7) visits in any one week;

8.3.10.3.5 Care furnished on a visiting basis in the insured’s home;

8.3.10.3.6 Services provided by a care provider as defined in this Section;

8.3.10.3.7 At-home recovery visits while the insured is covered under the policy or certificate and not otherwise excluded; and

8.3.10.3.8 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.

8.3.10.4 Coverage described in subsection 8.3.10.2 of this regulation is excluded for:

8.3.10.4.1 Home care visits paid for by Medicare or other government programs; and

8.3.10.4.2 Care provided by family members, unpaid volunteers or providers who are not care providers.

8.4 Standards for Plans K and L

an eight (8) weeks after the service date of the last Medicare approved home health care visit.

8.3.10.4 Coverage described in subsection 8.3.10.2 of this regulation is excluded for:

8.3.10.4.1 Home care visits paid for by Medicare or other government programs; and

8.3.10.4.2 Care provided by family members, unpaid volunteers or providers who are not care providers.

8.4 Standards for Plans K and L.

8.4.1 Standardized Medicare supplement benefit plan “K” shall consist of the following:

8.4.1.1 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;

8.4.1.2 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;

8.4.1.3 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;

8.4.1.4 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 subsection 8.4.1.10 of this regulation;

8.4.1.5 Skilled Nursing Facility Care: Coverage for fifty percent (50%) of the coinsurance amount for each day used from the 21st day through the 100 th 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 subsection 8.4.1.10 of this regulation;

8.4.1.6 Hospice Care: Coverage for fifty percent (50%) of cost shari

y Care: Coverage for fifty percent (50%) of the coinsurance amount for each day used from the 21st day through the 100 th 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 subsection 8.4.1.10 of this regulation;

8.4.1.6 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 subsection 8.4.1.10 of this regulation;

8.4.1.7 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 subsection 8.4.1.10 of this regulation;

8.4.1.8 Except for coverage provided in subsection 8.4.1.10 of this regulation, 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 subsection 8.4.1.10 of this regulation;

8.4.1.9 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

8.4.1.10 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

4.1.10 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.

8.4.2 Standardized Medicare supplement benefit plan “L” shall consist of the following:

8.4.2.1 The benefits described in subsections 8.1.1, 8.1.2, 8.1.3 and 8.1.9 of this regulation;

8.4.2.2 The benefit described in subsections 8.1.4, 8.1.5, 8.1.6, 8.1.7 and 8.1.8 of this regulation, but substituting seventy-five percent (75%) for fifty percent (50%); and

8.4.2.3 The benefit described in subsection 8.1.10, but substituting $2000 for $4000.

22 DE Reg. 1026 (06/01/19)

9.0 Benefit Standards for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery with an effective Date for Coverage on or After June 1, 2010

9.1 The following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this state with an effective date for 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 standards. No issuer may offer any 1990 Standardized Medicare supplement benefit plan for sale on or after June 1, 2010. Benefit standards applicable to Medicare supplement policies and certificates issued before June 1, 2010 remain subject to the requirements of 18 Del.C. Chapter 34. The following general standards apply to Medicare supplement policies and certificates and are in addition to all other requirements of this regulation

90 Standardized Medicare supplement benefit plan for sale on or after June 1, 2010. Benefit standards applicable to Medicare supplement policies and certificates issued before June 1, 2010 remain subject to the requirements of 18 Del.C. Chapter 34. The following general standards apply to Medicare supplement policies and certificates and are in addition to all other requirements of this regulation.

9.1.1 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 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 six (6) months before the effective date of coverage.

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

9.1.3 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.

9.1.4 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.

9.1.5 Each Medicare supplement policy shall be guaranteed renewable.

9.1.5.1 The issuer shall not cancel or non-renew the policy solely on the ground of health status of the individual.

9.1.5.2 The issuer shall not cancel or non-renew the policy for any reason other than nonpayment of premium or material misrepresentation

ermination of coverage of the insured, other than the nonpayment of premium.

9.1.5 Each Medicare supplement policy shall be guaranteed renewable.

9.1.5.1 The issuer shall not cancel or non-renew the policy solely on the ground of health status of the individual.

9.1.5.2 The issuer shall not cancel or non-renew the policy for any reason other than nonpayment of premium or material misrepresentation.

9.1.5.3 If the Medicare supplement policy is terminated by the group policyholder and is not replaced as provided under subsection 9.1.5.5 of this regulation, the issuer shall offer certificate holders an individual Medicare supplement policy which (at the option of the certificate holder):

9.1.5.3.1 Provides for continuation of the benefits contained in the group policy; or

9.1.5.3.2 Provides for benefits that otherwise meet the requirements of this Subsection.

9.1.5.4 If an individual is a certificate holder in a group Medicare Supplement policy and the individual terminates membership in the group, the issuer shall:

9.1.5.4.1 Offer the certificate holder the conversion opportunity described in subsection 9.1.5.3 of this regulation; or

9.1.5.4.2 At the option of the group policyholder, offer the certificate holder continuation of coverage under the group policy.

9.1.5.5 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

plement 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.

9.1.6 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.

9.1.7 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.

9.1.7.1 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

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.

9.1.7.2 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.

9.1.7.3 Reinstitution of coverages as described in subsections 9.1.7.1 and 9.1.7.2 of this regulation:

9.1.7.3.1 Shall not provide for any waiting period with respect to treatment of preexisting conditions;

9.1.7.3.2 Shall provide for resumption of coverage that is substantially equivalent to coverage in effect before the date of suspension; and

9.1.7.3.3 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.

9.2 Standards for Basic (Core) Benefits Common to Medicare Supplement Insurance Benefit Plans A, B, C, D, F, F with High Deductible, G, M and N

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.

9.2 Standards for Basic (Core) Benefits Common to Medicare Supplement Insurance Benefit Plans A, B, C, D, F, F with High Deductible, G, M and N. Every issuer of Medicare supplement insurance benefit plans 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.

9.2.1 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;

9.2.2 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;

9.2.3 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

t reserve day used;

9.2.3 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;

9.2.4 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;

9.2.5 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;

9.2.6 Hospice Care: Coverage of cost sharing for all Part A Medicare eligible hospice care and respite care expenses.

9.3 Standards for Additional Benefits. The following additional benefits shall be included in Medicare supplement benefit Plans B, C, D, F, F with High Deductible, G, M, and N as provided by subsection 11.1 of this regulation.

9.3.1 Medicare Part A Deductible: Coverage for one hundred percent (100%) of the Medicare Part A inpatient hospital deductible amount per benefit period.

9.3.2 Medicare Part A Deductible: Coverage for fifty percent (50%) of the Medicare Part A inpatient hospital deductible amount per benefit period.

9.3.3 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

9.3.2 Medicare Part A Deductible: Coverage for fifty percent (50%) of the Medicare Part A inpatient hospital deductible amount per benefit period.

9.3.3 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.

9.3.4 Medicare Part B Deductible: Coverage for one hundred percent (100%) of The Medicare Part B deductible amount per calendar year regardless of hospital confinement.

9.3.5 One Hundred Percent (100%) of the Medicare Part B Excess Charges: Coverage for all of the difference between the actual Medicare Part B charges as billed, not to exceed any charge limitation established by the Medicare program or state law, and the Medicare-approved Part B charge.

9.3.6 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.

22 DE Reg. 1026 (06/01/19)

10.0 Standard Medicare Supplement Benefit Plans for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or After July 1, 2009 with an effective date of coverage prior to June 1, 2010

10.1 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 subsection 8.2 of this regulation

ans for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or After July 1, 2009 with an effective date of coverage prior to June 1, 2010

10.1 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 subsection 8.2 of this regulation.

10.2 No groups, packages or combinations of Medicare supplement benefits other than those listed in this Section shall be offered for sale in this state, except as may be permitted in subsection 13.7 and in Section 14.0 of this regulation.

10.3 Benefit plans shall be uniform in structure, language, designation and format to the standard benefit plans “A” through “L” listed in this subsection and conform to the definitions in Section 4.0 of this regulation. Each benefit shall be structured in accordance with the format provided in subsections 8.2 and 8.3,or 8.4 of this regulation and list the benefits in the order shown in this subsection. For purposes of this Section, “ structure, language, and format ” means style, arrangement and overall content of a benefit.

10.4 An issuer may use, in addition to the benefit plan designations required in subsection 10.3 of this regulation, other designations to the extent permitted by law.

10.5 Make-up of benefit plans:

10.5.1 Standardized Medicare supplement benefit plan “A” shall be limited to the basic (core) benefits common to all benefit plans, as defined in subsection 8.2 of this regulation.

10.5.2 Standardized Medicare supplement benefit plan “B” shall include only the following: The core benefit as defined in subsection 8.2 of this regulation, plus the Medicare Part A deductible as defined in subsection 8.3.1 of this regulation

icare supplement benefit plan “A” shall be limited to the basic (core) benefits common to all benefit plans, as defined in subsection 8.2 of this regulation.

10.5.2 Standardized Medicare supplement benefit plan “B” shall include only the following: The core benefit as defined in subsection 8.2 of this regulation, plus the Medicare Part A deductible as defined in subsection 8.3.1 of this regulation.

10.5.3 Standardized Medicare supplement benefit plan “C” shall include only the following: The core benefit as defined in subsection 8.2 of this regulation, plus the Medicare Part A deductible, skilled nursing facility care, Medicare Part B deductible and medically necessary emergency care in a foreign country as defined in subsections 8.3.1, 8.3.2, 8.3.3 and 8.3.8 of this regulation respectively.

10.5.4 Standardized Medicare supplement benefit plan “D” shall include only the following: The core benefit (as defined in subsection 8.2 of this regulation), plus the Medicare Part A deductible, skilled nursing facility care, medically necessary emergency care in an foreign country and the at-home recovery benefit as defined in subsections 8.3.1, 8.3.2, 8.3.8 and 8.3.10 of this regulation, respectively.

10.5.5 Standardized Medicare supplement benefit plan “E” shall include only the following: The core benefit as defined in subsection 8.2 of this regulation, plus the Medicare Part A deductible, skilled nursing facility care, medically necessary emergency care in a foreign country and preventive medical care as defined in subsections 8.3.1, 8.3.2, 8.3.8 and 8.3.9 of this regulation, respectively

y.

10.5.5 Standardized Medicare supplement benefit plan “E” shall include only the following: The core benefit as defined in subsection 8.2 of this regulation, plus the Medicare Part A deductible, skilled nursing facility care, medically necessary emergency care in a foreign country and preventive medical care as defined in subsections 8.3.1, 8.3.2, 8.3.8 and 8.3.9 of this regulation, respectively.

10.5.6 Standardized Medicare supplement benefit plan “F” shall include only the following: The core benefit as defined in subsection 8.2 of this regulation, plus the Medicare Part A deductible, the skilled nursing facility care, the 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 subsections 8.3.1, 8.3.2, 8.3.3, 8.3.5 and 8.3.8 of this regulation, respectively.

10.5.7 Standardized Medicare supplement benefit high deductible plan “F” shall include only the following: 100% of covered expenses following the payment of the annual high deductible plan “F” deductible. The covered expenses include the core benefit as defined in subsection 8.2 of this regulation, plus the Medicare Part A deductible, skilled nursing facility care, 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 subsections 8.3.1, 8.3.2, 8.3.3, 8.3.5 and 8.3.8 of this regulation, respectively. The annual high deductible plan “F” deductible shall consist of out-of-pocket expenses, other than premiums, for services covered by the Medicare supplement plan “F” policy, and shall be in addition to any other specific benefit deductibles. The annual high deductible Plan “F” deductible shall be $1500 for 1998 and 1999, and shall be based on the calendar year

3.8 of this regulation, respectively. The annual high deductible plan “F” deductible shall consist of out-of-pocket expenses, other than premiums, for services covered by the Medicare supplement plan “F” policy, and shall be in addition to any other specific benefit deductibles. The annual high deductible Plan “F” deductible shall be $1500 for 1998 and 1999, and shall be based on the calendar year. It shall be adjusted annually thereafter by the Secretary to reflect the change in the Consumer Price Index for all urban consumers for the twelve-month period ending with August of the preceding year, and rounded to the nearest multiple of $10.

10.5.8 Standardized Medicare supplement benefit plan “G” shall include only the following: The core benefit as defined in subsection 8.2 of this regulation, plus the Medicare Part A deductible, skilled nursing facility care, eighty percent (80%) of the Medicare Part B excess charges, medically necessary emergency care in a foreign country, and the at-home recovery benefit as defined in subsections 8.3.1, 8.3.2, 8.3.4, 8.3.8 and 8.3.10 of this regulation, respectively.

10.5.9 Standardized Medicare supplement benefit plan “H” shall consist of only the following: The core benefit as defined in subsection 8.2 of this regulation, plus the Medicare Part A deductible, skilled nursing facility care, basic prescription drug benefit and medically necessary emergency care in a foreign country as defined in subsections 8.3.1, 8.3.2, 8.3.6 and 8.3.8 of this regulation, respectively. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005

on 8.2 of this regulation, plus the Medicare Part A deductible, skilled nursing facility care, basic prescription drug benefit and medically necessary emergency care in a foreign country as defined in subsections 8.3.1, 8.3.2, 8.3.6 and 8.3.8 of this regulation, respectively. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005.

10.5.10 Standardized Medicare supplement benefit plan “I” shall consist of only the following: The core benefit as defined in subsection 8.2 of this regulation, plus the Medicare Part A deductible, skilled nursing facility care, one hundred percent (100%) of the Medicare Part B excess charges, basic prescription drug benefit, medically necessary emergency care in a foreign country and at-home recovery benefit as Defined in subsections 8.3.1, 8.3.2, 8.3.5, 8.3.6, 8.3.8, and 8.3.10 respectively. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005.

10.5.11 Standardized Medicare supplement benefit plan “J” shall consist of only the following: The core benefit as defined in subsection 8.2 of this regulation, plus the Medicare Part A deductible, skilled nursing facility care, Medicare Part B deductible, one hundred percent (100%) of the Medicare Part B excess charges, extended prescription drug benefit, medically necessary emergency care in a foreign country, preventive medical care and at-home recovery benefit as defined in subsections 8.3.1, 8.3.2, 8.3.3, 8.3.5, 8.3.7, 8.3.8, 8.3.9, and 8.3.10 respectively. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005.

10.5.12 Standardized Medicare supplement benefit high deductible plan “J” shall consist of only the following: 100% of covered expenses following the payment of the annual high deductible plan “J” deductible

8.3.2, 8.3.3, 8.3.5, 8.3.7, 8.3.8, 8.3.9, and 8.3.10 respectively. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005.

10.5.12 Standardized Medicare supplement benefit high deductible plan “J” shall consist of only the following: 100% of covered expenses following the payment of the annual high deductible plan “J” deductible. The covered expenses include the core benefit as defined in subsection 8.2 of this regulation, plus the Medicare Part A deductible, skilled nursing facility care, Medicare Part B deductible, one hundred percent (100%) of the Medicare Part B excess charges, extended outpatient prescription drug benefit, medically necessary emergency care in a foreign country, preventive medical care benefit and at-home recovery benefit as defined in subsections 8.3.1, 8.3.2, 8.3.3, 8.3.5, 8.3.7, 8.3.8, 8.3.9, and 8.3.10 of this regulation, respectively. The annual high deductible plan “J” deductible shall consist of out-of-pocket expenses, other than premiums, for services covered by the Medicare supplement plan “J” policy, and shall be in addition to any other specific benefit deductibles. The annual deductible shall be $1500 for 1998 and 1999, and shall be based on a calendar year. It shall be adjusted annually thereafter by the Secretary to reflect the change in the Consumer Price Index for all urban consumers for the twelve-month period ending with August of the preceding year, and rounded to the nearest multiple of $10. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005.

10.6 Make-up of two Medicare supplement plans mandated by The Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA);

10.6.1 Standardized Medicare supplement benefit plan “K” shall consist of only those benefits described in subsection 8.4.1 of this regulation

tpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005.

10.6 Make-up of two Medicare supplement plans mandated by The Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA);

10.6.1 Standardized Medicare supplement benefit plan “K” shall consist of only those benefits described in subsection 8.4.1 of this regulation.

10.6.2 Standardized Medicare supplement benefit plan “L” shall consist of only those benefits described in subsection 8.4.2 of this regulation.

10.7 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 benefits provided in a policy or certificate that otherwise complies with the applicable standards. The new or innovative benefits may include benefits that are appropriate to Medicare supplement insurance, new or innovative, not otherwise available, cost-effective, and offered in a manner that is consistent with the goal of simplification of Medicare supplement policies. After December 31, 2005, the innovative benefit shall not include an outpatient prescription drug benefit.

22 DE Reg. 1026 (06/01/19)

11.0 Standard Medicare Supplement Benefit Plans for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery with an effective date on or After June 1, 2010

11.1 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 before June 1, 2010 remain subject to the requirements of 18 Del.C. §3403

verage 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 before June 1, 2010 remain subject to the requirements of 18 Del.C. §3403 .

11.1.1 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 subsection 9.2 of this regulation.

11.1.2 If an issuer makes available any of the additional benefits described in subsection 9.3, or offers standardized benefit Plans K or L (as described in subsections 11.5.8 and 11.5.9 of this regulation), 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 subsection 11.1.1 of this regulation, a policy form or certificate form containing either standardized benefit Plan C (as described in subsection 11.5.3 of this regulation) or standardized benefit Plan F (as described in subsection 11.5.5 of this regulation).

11.2 No groups, packages or combinations of Medicare supplement benefits other than those listed in this Section shall be offered for sale in this state, except as may be permitted in subsection 11.7 and in Section 13.0 of this regulation.

11.3 Benefit plans shall be uniform in structure, language, designation and format to the standard benefit plans listed in this subsection and conform to the definitions in Section 4.0 of this regulation. Each benefit shall be structured in accordance with the format provided in subsections 8.1.2 and 8.1.3 of this regulation; or, in the case of plans K or L, in subsections 11.5.8 or 11.5.9 of this regulation and list the benefits in the order shown

nguage, designation and format to the standard benefit plans listed in this subsection and conform to the definitions in Section 4.0 of this regulation. Each benefit shall be structured in accordance with the format provided in subsections 8.1.2 and 8.1.3 of this regulation; or, in the case of plans K or L, in subsections 11.5.8 or 11.5.9 of this regulation and list the benefits in the order shown. For purposes of this subsection, “ structure, language, and format ” means style, arrangement and overall content of a benefit.

11.4 In addition to the benefit plan designations required in subsection 11.3 of this regulation, an issuer may use other designations to the extent permitted by law.

11.5 Make-up of 2010 Standardized Benefit Plans:

11.5.1 Standardized Medicare supplement benefit Plan A shall include only the following: The basic (core) benefits as defined in subsection 9.2 of this regulation.

11.5.2 Standardized Medicare supplement benefit Plan B shall include only the following: The basic (core) benefit as defined in subsection 9.2 of this regulation, plus one hundred percent (100%) of the Medicare Part A deductible as defined in subsection 9.3.1 of this regulation.

11.5.3 Standardized Medicare supplement benefit Plan C shall include only the following: The basic (core) benefit as defined in subsection 9.2 of this regulation, 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 subsections 9.3.1, 9.3.3, 9.3.4, 9.3.5 and 9.3.6 of this regulation, respectively

following: The basic (core) benefit as defined in subsection 9.2 of this regulation, 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 subsections 9.3.1, 9.3.3, 9.3.4, 9.3.5 and 9.3.6 of this regulation, respectively.

11.5.4 Standardized Medicare supplement benefit Plan D shall include only the following: The basic (core) benefit (as defined in subsection 9.2 of this regulation), 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 subsections 9.3.1, 9.3.3, and 9.3.6 of this regulation, respectively.

11.5.5 Standardized Medicare supplement [regular] Plan F shall include only the following: The basic (core) benefit as defined in subsection of this regulation, 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 subsections 9.3.1, 9.3.3, 9.3.4, 9.3.5, and 9.3.6 of this regulation, respectively.

11.5.6 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 subsection 11.5.6.2 of this regulation

edically necessary emergency care in a foreign country as defined in subsections 9.3.1, 9.3.3, 9.3.4, 9.3.5, and 9.3.6 of this regulation, respectively.

11.5.6 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 subsection 11.5.6.2 of this regulation.

11.5.6.1 The basic (core) benefit as defined in subsection 9.2 of this regulation, 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 subsections 9.3.1, 9.3.3, 9.3.4, 9.3.5, and 9.3.6 of this regulation, respectively.

11.5.6.2 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 $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-month period ending with August of the preceding year, and rounded to the nearest multiple of ten dollars ($10).

11.5.7 Standardized Medicare supplement benefit Plan G shall include only the following: The basic (core) benefit as defined in subsection 9.2 of this regulation, 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 subsections 9.3.1, 9.3.3, 9.3.5, and 9.3.6 of this regulation, respectively

e following: The basic (core) benefit as defined in subsection 9.2 of this regulation, 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 subsections 9.3.1, 9.3.3, 9.3.5, and 9.3.6 of this regulation, respectively. Effective January 1, 2020, the standardized benefit plans described in subsection 12.1.4 of this regulation (re-designated Plan G High Deductible) may be offered to any individual who was eligible for Medicare prior to January 1, 2020.

11.5.8 Standardized Medicare supplement Plan K is mandated by The Medicare Prescription Drug, Improvement and Modernization Act of 2003, and shall include only the following:

11.5.8.1 Part A Hospital Coinsurance 61st through 90th days: Coverage of one hundred percent (100%) of the Part A hospital coinsurance amount for each day used from the 61 st through the 90 th day in any Medicare benefit period;

11.5.8.2 Part A Hospital Coinsurance, 91st through 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 91st through the 150th day in any Medicare benefit period;

11.5.8.3 Part A Hospitalization After 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 365 days

alization After 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 365 days. The provider shall accept the issuer’s payment as payment in full and may not bill the insured for any balance;

11.5.8.4 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 subsection 11.5.8.10 of this regulation;

11.5.8.5 Skilled Nursing Facility Care: Coverage for fifty percent (50%) of the coinsurance amount for each day used from the 21 st day through the 100 th 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 subsection 11.5.8.10 of this regulation ;

11.5.8.6 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 subsection 11.5.8.10 of this regulation;

11.5.8.7 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 subsection 11.5.8.10 of this regulation;

11.5.8.8 Part B Cost Sharing: Except for coverage provided in subsection 11.5.8.9 of this regulation, 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

l the out-of-pocket limitation is met as described in subsection 11.5.8.10 of this regulation;

11.5.8.8 Part B Cost Sharing: Except for coverage provided in subsection 11.5.8.9 of this regulation, 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 subsections 11.5.8.9 and 11.5.8.10 of this regulation;

11.5.8.9 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

11.5.8.10 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 $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.

11.5.9 Standardized Medicare supplement Plan L is mandated by The Medicare Prescription Drug, Improvement and Modernization Act of 2003, and shall include only the following:

11.5.9.1 The benefits described in subsections 11.5.8.1, 11.5.8.2, 11.5.8.3 and 11.5.8.9 of this regulation;

11.5.9.2 The benefit described in subsections 11.5.8.4, 11.5.8.5, and 11.5.8.8 of this regulation, respectively, but substituting seventy-five percent (75%) for fifty percent (50%); and

11.5.9.3 The benefit described in subsection 11.5.8.10 of this regulation, but substituting $2000 for $4000

.5.9.1 The benefits described in subsections 11.5.8.1, 11.5.8.2, 11.5.8.3 and 11.5.8.9 of this regulation;

11.5.9.2 The benefit described in subsections 11.5.8.4, 11.5.8.5, and 11.5.8.8 of this regulation, respectively, but substituting seventy-five percent (75%) for fifty percent (50%); and

11.5.9.3 The benefit described in subsection 11.5.8.10 of this regulation, but substituting $2000 for $4000.

11.5.10 Standardized Medicare supplement Plan M shall include only the following: The basic (core) benefit as defined in subsection 9.2 of this regulation, 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 subsections 9.3.2, 9.3.3 and 9.3.6 of this regulation, respectively.

11.5.11 Standardized Medicare supplement Plan N shall include only the following: The basic (core) benefit as defined in subsection 9.2 of this regulation, 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 subsections 9.3.1, 9.3.3 and 9.3.6 of this regulation, respectively, with co-payments in the following amounts:

11.5.11.1 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

11.5.11.2 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.

11.6 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

nsured is admitted to any hospital and the emergency visit is subsequently covered as a Medicare Part A expense.

11.6 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.

22 DE Reg. 1026 (06/01/19)

12.0 Standard Medicare Supplement Benefit Plans for 2020 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery to Individuals Newly Eligible for Medicare on or After January 1, 2020.

12.1 The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires the following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this state to individuals newly eligible for Medicare on or after January 1, 2020. No policy or certificate that provides coverage of the Medicare Part B deductible may be advertised, solicited, delivered or issued for delivery in this state as a Medicare supplement policy or certificate to individuals newly eligible for Medicare on or after January 1, 2020. All policies must comply with the following benefit standards. Benefit plan standards applicable to Medicare supplement policies and certificates issued to individuals eligible for Medicare before January 1, 2020, remain subject to the requirements of 18 Del.C. § 3403

this state as a Medicare supplement policy or certificate to individuals newly eligible for Medicare on or after January 1, 2020. All policies must comply with the following benefit standards. Benefit plan standards applicable to Medicare supplement policies and certificates issued to individuals eligible for Medicare before January 1, 2020, remain subject to the requirements of 18 Del.C. § 3403 .

12.2 Benefit Requirements. The standards and requirements of Section 11.0 of this regulation shall apply to all Medicare supplement policies or certificates delivered or issued for delivery to individuals newly eligible for Medicare on or after January 1, 2020, with the following exceptions:

12.2.1 Standardized Medicare supplement benefit Plan C is re-designated as Plan D and shall provide the benefits contained in subsection 11.5.3 of this regulation but shall not provide coverage for one hundred percent (100%) or any portion of the Medicare Part B deductible.

12.2.2 Standardized Medicare supplement benefit Plan F is re-designated as Plan G and shall provide the benefits contained in subsection 11.5.5 of this regulation but shall not provide coverage for one hundred percent (100%) or any portion of the Medicare Part B deductible.

12.2.3 Standardized Medicare supplement benefit plans C, F, and F with High Deductible may not be offered to individuals newly eligible for Medicare on or after January 1, 2020.

12.2.4 Standardized Medicare supplement benefit Plan F With High Deductible is re-designated as Plan G With High Deductible and shall provide the benefits contained in subsection 11.5.6 of this regulation but shall not provide coverage for one hundred percent (100%) or any portion of the Medicare Part B deductible; provided further that, the Medicare Part B deductible paid by the beneficiary shall be considered an out-of-pocket expense in meeting the annual high deductible

s re-designated as Plan G With High Deductible and shall provide the benefits contained in subsection 11.5.6 of this regulation but shall not provide coverage for one hundred percent (100%) or any portion of the Medicare Part B deductible; provided further that, the Medicare Part B deductible paid by the beneficiary shall be considered an out-of-pocket expense in meeting the annual high deductible.

12.2.5 The reference to Plans C or F contained in subsection 11.1.2 of this regulation is deemed a reference to Plans D or G for purposes of this Section.

12.3 Applicability to Certain Individuals. This subsection applies only to individuals that are newly eligible for Medicare on or after January 1, 2020:

12.3.1 By reason of attaining age 65 on or after January 1, 2020; or

12.3.2 By reason of entitlement to benefits under subsection 12.2 of this regulation, pursuant to Section 226(b) or 226A of the Social Security Act, or who is deemed to be eligible for benefits under section 226(a) of the Social Security Act on or after January 1, 2020.

12.4 Guaranteed Issue for Eligible Persons. For purposes of subsection 15.5 of this regulation, in the case of any individual newly eligible for Medicare on or after January 1, 2020, any reference to a Medicare supplement policy C or F (including F With High Deductible) shall be deemed to be a reference to Medicare supplement policy D or G (including G With High Deductible) respectively that meet the requirements of subsection 12.2 of this regulation.

12.5 Applicability to Waivered States. In the case of a State described in Section 1882(p)(6) of the Social Security Act (“waivered” alternative simplification states) MACRA prohibits the coverage of the Medicare Part B deductible for any Medicare supplement policy sold or issued to an individual that is newly eligible for Medicare on or after January 1, 2020.

12.6 Offer of Re-designated Plans to Individuals Other Than Newly Eligible

. In the case of a State described in Section 1882(p)(6) of the Social Security Act (“waivered” alternative simplification states) MACRA prohibits the coverage of the Medicare Part B deductible for any Medicare supplement policy sold or issued to an individual that is newly eligible for Medicare on or after January 1, 2020.

12.6 Offer of Re-designated Plans to Individuals Other Than Newly Eligible. On or after January 1, 2020, the standardized benefit plans described in subsection 12.2.4, of this regulation may be offered to any individual who was eligible for Medicare prior to January 1, 2020 in addition to the standardized plans described in subsection 11.5 of this regulation.

22 DE Reg. 1026 (06/01/19)

13.0 Medicare Select Policies and Certificates

13.1 General requirements

13.1.1 This Section shall apply to Medicare Select policies and certificates, as defined in this Section.

13.1.2 No policy or certificate may be advertised as a Medicare Select policy or certificate unless it meets the requirements of this Section.

13.2 For the purposes of this Section:

“ Complaint ” means any dissatisfaction expressed by an individual concerning a Medicare Select issuer or its network providers.

“ Grievance ” means dissatisfaction expressed in writing by an individual insured under a Medicare Select policy or certificate with the administration, claims practices, or provision of services concerning a Medicare Select issuer or its network providers.

“ Medicare Select issuer ” means an issuer offering, or seeking to offer, a Medicare Select policy or certificate.

“ Medicare Select policy ” or “ Medicare Select certificate ” mean respectively a Medicare supplement policy or certificate that contains restricted network provisions.

“ Network provider ” means a provider of health care, or a group of providers of health care, which has entered into a written agreement with the issuer to provide benefits insured under a Medicare Select policy

icy or certificate.

“ Medicare Select policy ” or “ Medicare Select certificate ” mean respectively a Medicare supplement policy or certificate that contains restricted network provisions.

“ Network provider ” means a provider of health care, or a group of providers of health care, which has entered into a written agreement with the issuer to provide benefits insured under a Medicare Select policy.

“ Restricted network provision ” means any provision which conditions the payment of benefits, in whole or in part, on the use of network providers.

“ Service area ” means the geographic area approved by the Commissioner within which an issuer is authorized to offer a Medicare Select policy.

13.3 The Commissioner may authorize an issuer to offer a Medicare Select policy or certificate, pursuant to this Section and Section 4358 of the Omnibus Budget Reconciliation Act (OBRA) of 1990 if the Commissioner finds that the issuer has satisfied all of the requirements of this regulation.

13.4 A Medicare Select issuer shall not issue a Medicare Select policy or certificate in this state until its plan of operation has been approved by the Commissioner.

13.5 A Medicare Select issuer shall file a proposed plan of operation with the Commissioner in a format prescribed by the Commissioner. The plan of operation shall contain at least the following information:

13.5.1 Evidence that all covered services that are subject to restricted network provisions are available and accessible through network providers, including a demonstration that:

13.5.1.1 Services can be provided by network providers with reasonable promptness with respect to geographic location, hours of operation and after-hour care. The hours of operation and availability of after-hour care shall reflect usual practice in the local area. Geographic availability shall reflect the usual travel times within the community

h network providers, including a demonstration that:

13.5.1.1 Services can be provided by network providers with reasonable promptness with respect to geographic location, hours of operation and after-hour care. The hours of operation and availability of after-hour care shall reflect usual practice in the local area. Geographic availability shall reflect the usual travel times within the community.

13.5.1.2 The number of network providers in the service area is sufficient, with respect to current and expected policyholders, either:

13.5.1.2.1 To deliver adequately all services that are subject to a restricted network provision; or

13.5.1.2.2 To make appropriate referrals.

13.5.1.3 There are written agreements with network providers describing specific responsibilities.

13.5.1.4 Emergency care is available twenty-four (24) hours per day and seven (7) days per week.

13.5.1.5 In the case of covered services that area subject to a restricted network provision and are provided on a prepaid basis, there are written agreements with network providers prohibiting the providers from billing or otherwise seeking reimbursement from or recourse against any individual insured under a Medicare Select policy or certificate. This subsection shall not apply to supplemental charges or coinsurance amounts as stated in the Medicare Select policy or certificate.

13.5.2 A statement or map providing a clear description of the service area.

13.5.3 A description of the grievance procedure to be utilized.

13.5.4 A description of the quality assurance program, including:

13.5.4.1 The formal organizational structure;

13.5.4.2 The written criteria for selection, retention and removal of network providers; and

13.5.4.3 The procedures for evaluating quality of care provided by network providers, and the process to initiate corrective action when warranted.

13.5.5 A list and description, by specialty, of the network providers

f the quality assurance program, including:

13.5.4.1 The formal organizational structure;

13.5.4.2 The written criteria for selection, retention and removal of network providers; and

13.5.4.3 The procedures for evaluating quality of care provided by network providers, and the process to initiate corrective action when warranted.

13.5.5 A list and description, by specialty, of the network providers.

13.5.6 Copies of the written information proposed to be used by the issuer to comply with subsection 13.9 of this regulation.

13.5.7 Any other information requested by the Commissioner.

13.6 Plan changes filed with Commissioner

13.6.1 A Medicare Select issuer shall file any proposed changes to the plan of operation, except for changes to the list of network providers, with the Commissioner prior to implementing the changes. Changes shall be considered approved by the Commissioner after thirty (30) days unless specifically disapproved.

13.6.2 An updated list of network providers shall be filed with the Commissioner at least quarterly.

13.7 A Medicare Select policy or certificate shall not restrict payment for covered services provided by non-network providers if:

13.7.1 The services are for symptoms requiring emergency care or are immediately required for an unforeseen illness, injury or a condition; and

13.7.2 It is not reasonable to obtain services through a network provider.

13.8 A Medicare Select policy or certificate shall provide payment for full coverage under the policy for covered services that are not available through network providers.

13.9 A Medicare Select issuer shall make full and fair disclosure in writing of the provisions, restrictions and limitations of the Medicare Select policy or certificate to each applicant

in services through a network provider.

13.8 A Medicare Select policy or certificate shall provide payment for full coverage under the policy for covered services that are not available through network providers.

13.9 A Medicare Select issuer shall make full and fair disclosure in writing of the provisions, restrictions and limitations of the Medicare Select policy or certificate to each applicant. This disclosure shall include at least the following:

13.9.1 An outline of coverage sufficient to permit the applicant to compare the coverage and premiums of the Medicare Select policy or certificate with:

13.9.1.1 Other Medicare supplement policies or certificates offered by the issuer; and

13.9.1.2 Other Medicare Select policies or certificates.

13.9.2 A description (including address, phone number and hours of operation) of the network providers, including primary care physicians, specialty physicians, hospitals and other providers.

13.9.3 A description of the restricted network provisions, including payments for coinsurance and deductibles when providers other than network providers are utilized. Except to the extent specified in the policy or certificate, expenses incurred when using out-of-network providers do not count toward the out-of-pocket annual limit contained in plans K and L.

13.9.4 A description of coverage for emergency and urgently needed care and other out-of-service area coverage.

13.9.5 A description of limitations on referrals to restricted network providers and to other providers.

13.9.6 A description of the policyholder’s rights to purchase any other Medicare supplement policy or certificate otherwise offered by the issuer.

13.9.7 A description of the Medicare Select issuer’s quality assurance program and grievance procedure

care and other out-of-service area coverage.

13.9.5 A description of limitations on referrals to restricted network providers and to other providers.

13.9.6 A description of the policyholder’s rights to purchase any other Medicare supplement policy or certificate otherwise offered by the issuer.

13.9.7 A description of the Medicare Select issuer’s quality assurance program and grievance procedure.

13.10 Prior to the sale of a Medicare Select policy or certificate, a Medicare Select issuer shall obtain from the applicant a signed and dated form stating that the applicant has received the information provided pursuant to subsection 13.9 of this regulation and that the applicant understands the restrictions of the Medicare Select policy or certificate.

13.11 A Medicare Select issuer shall have and use procedures for hearing complaints and resolving written grievances from the subscribers. The procedures shall be aimed at mutual agreement for settlement and may include arbitration procedures.

13.11.1 The grievance procedure shall be described in the policy and certificates and in the outline of coverage.

13.11.2 At the time the policy or certificate is issued, the issuer shall provide detailed information to the policyholder describing how a grievance may be registered with the issuer.

13.11.3 Grievances shall be considered in a timely manner and shall be transmitted to appropriate decision-makers who have authority to fully investigate the issue and take corrective action.

13.11.4 If a grievance is found to be valid, corrective action shall be taken promptly.

13.11.5 All concerned parties shall be notified about the results of a grievance.

13.11.6 The issuer shall report no later than each March 31 st to the Commissioner regarding its grievance procedure. The report shall be in a format prescribed by the Commissioner and shall contain the number of grievances filed in the past year and a summary of the subject, nature and resolution of such grievances

13.11.5 All concerned parties shall be notified about the results of a grievance.

13.11.6 The issuer shall report no later than each March 31 st to the Commissioner regarding its grievance procedure. The report shall be in a format prescribed by the Commissioner and shall contain the number of grievances filed in the past year and a summary of the subject, nature and resolution of such grievances.

13.12 At the time of initial purchase, a Medicare Select issuer shall make available to each applicant for a Medicare Select policy or certificate the opportunity to purchase any Medicare supplement policy or certificate otherwise offered by the issuer.

13.13 At the request of an individual insured under a Medicare Select policy or certificate, a Medicare Select issuer shall make available to the individual insured the opportunity to purchase a Medicare supplement policy or certificate offered by the issuer which has comparable or lesser benefits and which does not contain a restricted network provision. The issuer shall make the policies or certificates available without requiring evidence of insurability after the Medicare Select policy or certificate has been in force for six (6) months.

13.14 For the purposes of this subsection, a Medicare supplement policy or certificate will be considered to have comparable or lesser benefits unless it contains one or more significant benefits not included in the Medicare Select policy or certificate being replaced. For the purposes of this subsection, a significant benefit means coverage for the Medicare Part A deductible, coverage for at-home recovery services or coverage for Part B excess charges.

13.15 Medicare Select policies and certificates shall provide for continuation of coverage in the event the Secretary of Health and Human Services determines that Medicare Select policies and certificates issued pursuant to this Section should be discontinued due to either the failure of the Medicare Select Program to be reauthorized under law or its substantial amendment

or Part B excess charges.

13.15 Medicare Select policies and certificates shall provide for continuation of coverage in the event the Secretary of Health and Human Services determines that Medicare Select policies and certificates issued pursuant to this Section should be discontinued due to either the failure of the Medicare Select Program to be reauthorized under law or its substantial amendment.

13.15.1 Each Medicare Select issuer shall make available to each individual insured under a Medicare Select policy or certificate the opportunity to purchase any Medicare supplement policy or certificate offered by the issuer which has comparable or lesser benefits and which does not contain a restricted network provision. The issuer shall make the policies and

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