# 031 Ch. 275: Ch. 275: Medicare Supplement Insurance

> Maine · Regulations · In force

URL: https://www.frixlaw.com/law-library/statutes/STATE_ME_CMR_00_031_275

## Section

- **Citation:** 031 Ch. 275
- **Heading:** Ch. 275: Medicare Supplement Insurance
- **Jurisdiction:** Maine
- **Kind:** Regulations
- **Status:** In force
- **Text as of:** August 14, 2026
- **Source:** Compiled text
- **Location:** Code of Maine Rules / -031 Department of Professional and Financial Regulation Rules / Ch. 275

## Text

Section 1.	Purpose	2
Section 2.	Authority	2
Section 3.	Applicability and Scope	2
Section 4.	Definitions	2
Section 5.	Policy Definitions and Terms	6
Section 6.	Policy Provisions	7
Section 8.	Benefit Standards for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or after January 1, 1992 and with an Effective Date of Coverage Prior to June 1, 2010	8
Section 8.1	Benefit Standards for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery with an Effective Date of Coverage on or After June 1, 2010	17
Section 9.	Standard Medicare Supplement Benefit Plans for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or After January 1, 1992 and with an Effective Date of Coverage Prior to June 1, 2010	22
Section 9.1	Standard Medicare Supplement Benefit Plans for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery with an Effective Date of Coverage on or After June 1, 2010	25
Section 9.2	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………………………..…………….29
Section 10.	Medicare Select Policies and Certificates	31
Section 11.	Open Enrollment	36
Section 12.	Guaranteed Issue for Eligible Persons	37
Section 13.	Standards for Claims Payment	42
Section 14.	Loss Ratio Standards and Refund or Credit of Premium	43
Section 15.	Filing and Approval of Policies and Certificates and Premium Rates	46
Section 16.	Permitted Compensation Arrangements	52
Section 17.	Required Disclosure Provisions	53
Section 18.	Requirements for Application Forms and Replacement Coverage	89
Section 19.	Filing Requirements for Advertising	95
Section 20.	Standards for Marketing	95
Section 21.	Appropriateness of Recommended Purchase and Excessive Insurance	96
Section 22.	Reporting of Multiple Policies	97
Section 23
46
Section 16.	Permitted Compensation Arrangements	52
Section 17.	Required Disclosure Provisions	53
Section 18.	Requirements for Application Forms and Replacement Coverage	89
Section 19.	Filing Requirements for Advertising	95
Section 20.	Standards for Marketing	95
Section 21.	Appropriateness of Recommended Purchase and Excessive Insurance	96
Section 22.	Reporting of Multiple Policies	97
Section 23.	Prohibition Against Preexisting Conditions, Waiting Periods, Elimination Periods and Probationary Periods in Replacement Policies or Certificates	97
Section 24.	Prohibition Against Use of Genetic Information and Requests for Genetic Testing	98
Section 25………	Separability………………..………………………………………………………………………………101
Section 26………	Effective Date…………………………………………………………………….………………………101
APPENDIX A	..	.102
APPENDIX B 106
APPENDIX C	.	107
Section 1.	Purpose
The purpose of this Rule 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.
Section 2.	Authority
This Rule is issued pursuant to the authority vested in the Superintendent of Insurance under 24 M.R.S.A. § 2317-B and 24-A M.R.S.A. §§ 212, 2413(1)(F), 4207(9), 5002-A, 5002-B, 5005, 5010-A, 5011, and Resolve 2013 Chapter 19.
Section 3.	Applicability and Scope
A.	Except as otherwise specifically provided in Sections 13, 14, 17 and 22, this Rule shall apply to:
(1)	All Medicare supplement policies delivered or issued for delivery in this State on or after the effective date of this Rule, and
R.S.A. § 2317-B and 24-A M.R.S.A. §§ 212, 2413(1)(F), 4207(9), 5002-A, 5002-B, 5005, 5010-A, 5011, and Resolve 2013 Chapter 19.
Section 3.	Applicability and Scope
A.	Except as otherwise specifically provided in Sections 13, 14, 17 and 22, this Rule shall apply to:
(1)	All Medicare supplement policies delivered or issued for delivery in this State on or after the effective date of this Rule, and
(2)	All certificates issued under group Medicare supplement policies which certificates have been delivered or issued for delivery in this State.
Drafting Note: For policies or certificates issued or delivered prior to January 1, 1992 see Bureau of Insurance Rule 270, in addition to any applicable sections of this Rule 275.
B.	Section 6(D) of this Rule shall apply to all Medicare supplement policies renewed in this State on or after the effective date of the 2005 amendments.
C.	This Rule shall not apply to a policy 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.
Section 4.	Definitions
For purposes of this Rule:
A.	“Applicant” means:
(1)	In the case of an individual Medicare supplement policy, the person who seeks to contract for benefits; and
(2)	In the case of a group Medicare supplement policy, the proposed certificate holder.
B.	(Repealed)
C.	“Certificate” means any certificate delivered or issued for delivery in this State under a group Medicare supplement policy.
D.	“Certificate form” means the form on which the certificate is delivered or issued for delivery by the issuer.
E.	“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 ninety (90) days.
F
s State under a group Medicare supplement policy.
D.	“Certificate form” means the form on which the certificate is delivered or issued for delivery by the issuer.
E.	“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 ninety (90) days.
F.	(1)	“Creditable coverage” means, with respect to an individual, coverage for medical expenses of the individual provided under any of the following:
a.	A group health plan;
b.	Health insurance coverage;
c.	Part A or Part B of Title XVIII of the Social Security Act (Medicare) or a Medicare Advantage plan;
d.	Title XIX of the Social Security Act (Medicaid), other than coverage consisting solely of benefits under Section 1928;
e.	Chapter 55 of Title 10 United States Code (CHAMPUS);
f.	A medical care program of the Indian Health Service or of a tribal organization;
g.	A state health benefits risk pool;
h.	A health plan offered under chapter 89 of Title 5 United States Code (Federal Employees Health Benefits Program);
i.	A public health plan as defined in Sec. 2590.701-4(a)(1)(ix) of Title 29 C.F.R.; and
j.	A health benefit plan under Section 5(e) of the Peace Corps Act (22 United States Code 2504(e)).
(2)	“Creditable coverage” shall not include one or more, or any combination of, the following:
a.	Coverage only for accident or disability income insurance, or any combination thereof;
b.	Coverage issued as a supplement to liability insurance;
c.	Liability insurance, including general liability insurance and automobile liability insurance;
d.	Workers’ compensation or similar insurance;
e. Automobile medical payment insurance;
f.	Credit-only insurance;
g.	Coverage for on-site medical clinics; and
h.	Other similar insurance coverage, specified in federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits.
including general liability insurance and automobile liability insurance;
d.	Workers’ compensation or similar insurance;
e. Automobile medical payment insurance;
f.	Credit-only insurance;
g.	Coverage for on-site medical clinics; and
h.	Other similar insurance coverage, specified in federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits.
(3)	“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:
a.	Limited scope dental or vision benefits;
b.	Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; and
c.	Such other similar, limited benefits as are specified in federal regulations.
(4)	“Creditable coverage” shall not include the following benefits if offered as independent, noncoordinated benefits:
a.	Coverage only for a specified disease or illness; and
b.	Hospital indemnity or other fixed indemnity insurance.
(5)	“Creditable coverage” shall not include the following if it is offered as a separate policy, certificate or contract of insurance:
a.	Medicare supplemental health insurance as defined under Section 1882(g)(1) of the Social Security Act;
b.	Coverage supplemental to the coverage provided under chapter 55 of Title 10, United States Code; and
c.	Similar supplemental coverage provided to coverage under a group health plan.
G.	“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). “Employee welfare benefit plan” also includes employee health coverage continued pursuant to the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA) and 24-A M.R.S. § 2809-A(11).
H
ed to coverage under a group health plan.
G.	“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). “Employee welfare benefit plan” also includes employee health coverage continued pursuant to the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA) and 24-A M.R.S. § 2809-A(11).
H.	“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.
I.	“Issuer” includes insurance companies, fraternal benefit societies, health care service plans, health maintenance organizations, and any other entity delivering or issuing for delivery Medicare supplement policies or certificates in this State.
J.	“Medicare” means the “Health Insurance for the Aged Act,” Title XVIII of the Social Security Amendments of 1965, as then constituted or later amended.
K.	“Medicare Advantage plan” means a plan of coverage for health benefits under Medicare Part C as defined in [refer to definition of Medicare Advantage plan in 42 U.S.C. § 1395w-28(b)(1)], and includes:
(1)	Coordinated care plans which 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;
(2)	Medical savings account plans coupled with a contribution into a Medicare Advantage medical savings account; and
and includes:
(1)	Coordinated care plans which 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;
(2)	Medical savings account plans coupled with a contribution into a Medicare Advantage medical savings account; and
(3)	Medicare Advantage private fee-for-service plans.
L.	“Medicare supplement policy” means a group or individual policy of accident and sickness insurance or a subscriber contract of hospital and medical service organizations 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. Sections 1395 et seq.) or an issued policy under a demonstration project specified in U.S.C. § 1395(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 §1833(a)(1)(A) of the Social Security Act.
M. “Pre-standardized benefit Plan,” or “Pre-standardized plan” means a group or individual policy of Medicare supplement insurance issued prior to January 1, 1992.
N.	“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 with an effective date of coverage 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.
O
January 1, 1992.
N.	“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 with an effective date of coverage 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.
O.	“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 of coverage on or after June 1, 2010.
P.	“Policy form” means the form on which the policy is delivered or issued for delivery by the issuer.
Q.	“Secretary” means the Secretary of the United States Department of Health and Human Services.
R.	“Superintendent” means the Superintendent of Insurance.
Section 5.	Policy Definitions and Terms
No policy or certificate may be advertised, solicited or issued for delivery in this State as a Medicare supplement policy or certificate unless such policy or certificate contains definitions or terms which conform to the requirements of this section.
A.	“Accident,” “Accidental Injury,” or “Accidental Means” shall be defined to employ “result” language and shall not include words which establish an accidental means test or use words such as “external, violent, visible wounds” or similar words of description or characterization.
(1)	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 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.”
ible wounds” or similar words of description or characterization.
(1)	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 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.”
(2)	The definition may, however, exclude 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.
B.	“Benefit Period” or “Medicare Benefit Period” shall not be defined more restrictively than as defined in the Medicare program.
C.	“Convalescent Nursing Home,” “Extended Care Facility,” or “Skilled Nursing Facility” shall not be defined more restrictively than as defined in the Medicare program.
D.	“Health Care Expenses” means, for purposes of Section 14, expenses of health maintenance organizations associated with the delivery of health care services, which expenses are analogous to incurred losses of insurers.
E.	“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 Health Care Organizations or by the American Osteopathic Association Healthcare Facilities Accreditation Program, but not more restrictively than as defined in the Medicare program.
F.	“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.
G
lth 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.
G.	“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.
H.	“Physician” shall not be defined more restrictively than as defined in the Medicare program.
I.	“Sickness” shall not be defined to be more restrictive than the following:
“Sickness means illness or disease of an insured person.”
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.
Section 6.	Policy Provisions
A.	Except for permitted preexisting condition clauses as described in Section 8 and in Sections 8(A)(1) and 8.1(A)(1) of this Rule, 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.
B.	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.
C.	No Medicare supplement policy or certificate in force in the State shall contain benefits which duplicate benefits provided by Medicare.
D.	(1)	Subject to Sections 8(A)(4), and 8(A)(5) of this Rule, 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.
ent policy or certificate in force in the State shall contain benefits which duplicate benefits provided by Medicare.
D.	(1)	Subject to Sections 8(A)(4), and 8(A)(5) of this Rule, 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.
(2)	A Medicare supplement policy with benefits for outpatient prescription drugs shall not be issued after December 31, 2005.
(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:
a.	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;
b.	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.
Section 7.	(Repealed)
Section 8.	Benefit Standards for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or after January 1, 1992 and with an Effective Date of Coverage Prior to June 1, 2010
The following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this State on or after January 1, 1992 and with an effective date of coverage 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.
A.	General Standards. The following standards apply to Medicare supplement policies and certificates and are in addition to all other requirements of this Rule.
te of coverage 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.
A.	General Standards. The following standards apply to Medicare supplement policies and certificates and are in addition to all other requirements of this Rule.
(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 the loss 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.”
(2)	A Medicare supplement policy or certificate shall not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents.
(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, copayment, or coinsurance amounts. Premiums may be modified to correspond with such changes.
(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.
coincide with any changes in the applicable Medicare deductible, copayment, or coinsurance amounts. Premiums may be modified to correspond with such changes.
(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.
(5)	Each Medicare supplement policy shall be guaranteed renewable.
a.	The issuer shall not cancel or nonrenew the policy solely on the ground of health status of the individual; and
b.	The issuer shall not cancel or nonrenew the policy for any reason other than nonpayment of premium or material misrepresentation.
c.	If the Medicare supplement policy is terminated by the group policyholder and is not replaced as provided under Section 8(A)(5)(e), the issuer shall offer each certificate holder an individual Medicare supplement policy which (at the option of the certificate holder):
i.	Provides for continuation of the benefits contained in the group policy, or
ii.	Provides for benefits that otherwise meet the requirements of this subsection.
d.	If an individual is a certificate holder in a group Medicare supplement policy and the individual terminates membership in the group, the issuer shall:
i.	Offer the certificate holder the conversion opportunity described in Section 8(A)(5)(c); or
ii.	At the option of the group policyholder, offer the certificate holder continuation of coverage under the group policy.
e.	If a group Medicare supplement policy is replaced by another group Medicare supplement policy purchased by the same policyholder, the issuer of the replacement policy shall offer coverage to all persons covered under the old group policy on its date of termination. Coverage under the new policy shall not result in any exclusion for preexisting conditions that would have been covered under the group policy being replaced.
f
ent policy is replaced by another group Medicare supplement policy purchased by the same policyholder, the issuer of the replacement policy shall offer coverage to all persons covered under the old group policy on its date of termination. Coverage under the new policy shall not result in any exclusion for preexisting conditions that would have been covered under the group policy being replaced.
f.	If a Medicare supplement policy eliminates an outpatient prescription drug benefit as a result of requirements imposed by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, the modified policy shall be deemed to satisfy the guaranteed renewal requirements of this paragraph.
(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.
A carrier issuing a subsequent Medicare supplement policy may not deny any claim otherwise covered under the policy on the basis that the enrollee is entitled to an extension of coverage under a prior policy pursuant to this paragraph, unless the prior carrier has paid the claim or has agreed in writing that it is providing coverage for the claim.  If the prior carrier does not agree in writing to provide coverage for the claim, any disputes over the carriers’ respective responsibilities for payment may be resolved in accordance with the procedures applicable to medical coverage as set forth in Bureau of Insurance Rule 790.
aph, unless the prior carrier has paid the claim or has agreed in writing that it is providing coverage for the claim.  If the prior carrier does not agree in writing to provide coverage for the claim, any disputes over the carriers’ respective responsibilities for payment may be resolved in accordance with the procedures applicable to medical coverage as set forth in Bureau of Insurance Rule 790.
(7)	a.	A Medicare supplement policy or certificate shall provide that benefits and premiums under the policy or certificate shall be suspended at the request of the policyholder or certificate holder for the period (not to exceed twenty-four (24) months) in which the policyholder or certificate holder has applied for and is determined to be entitled to medical assistance under Title XIX of the Social Security Act, but only if the policyholder or certificate holder notifies the issuer of such policy or certificate within ninety (90) days after the date the individual is notified that he or she is entitled to such assistance.
b.	If suspension occurs and if the policyholder or certificate holder loses entitlement to medical assistance, such policy or certificate shall be automatically reinstituted, effective as of the date of termination of such entitlement, if the policyholder or certificate holder provides notice of loss of entitlement within ninety (90) days after the date he or she is notified of loss, and pays the premium attributable to the period beginning on the date of termination of entitlement.
c.	Each Medicare supplement policy shall provide that benefits and premiums under the policy shall be suspended (for the period 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)
ent.
c.	Each Medicare supplement policy shall provide that benefits and premiums under the policy shall be suspended (for the period 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 90 days after the date of such loss and pays the premium attributable to the period beginning on the date of termination of entitlement.
d.	Reinstitution of such coverages:
i.	Shall not provide for any waiting period with respect to treatment of preexisting conditions;
ii.	Shall provide for resumption of coverage that is substantially equivalent to coverage in effect before the date of such suspension. If the suspended Medicare supplement policy provided coverage for outpatient prescription drugs, reinstitution of the policy for Medicare Part D enrollees shall be without coverage for outpatient prescription drugs and shall otherwise provide substantially equivalent coverage to the coverage in effect before the date of suspension; and
iii.	Shall provide for classification of premiums on terms at least as favorable to the policyholder or certificate holder as the premium classification terms that would have applied to the policyholder or certificate holder had the coverage not been suspended.
ption drugs and shall otherwise provide substantially equivalent coverage to the coverage in effect before the date of suspension; and
iii.	Shall provide for classification of premiums on terms at least as favorable to the policyholder or certificate holder as the premium classification terms that would have applied to the policyholder or certificate holder had the coverage not been suspended.
(8) An issuer must make a written offer to each of its Medicare supplement policyholders or certificate holders with a 1990 standardized plan (as described in Section 9 of this Rule) to exchange the plan for a 2010 standardized plan (as described in Section 9.1 of this Rule). A written offer to exchange the plan for a current standardized plan must also be included in any subsequent notice of rate increase. The plans offered and any subsequent exchange must be consistent with Sections 12(D) and 23.
B.	Standards for Basic (Core) Benefits Common to Benefit Plans A-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.
(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;
(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;
he basic core package, but not in lieu of it.
(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;
(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;
(3)	Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 100% of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system (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;
Drafting Note: The issuer is required to pay whatever amount Medicare would have paid as if Medicare was covering the hospitalization. The “or other Medicare appropriate standard of payment” provision means the manner in which Medicare would have paid. The issuer stands in the place of Medicare, and so the provider must accept the issuer’s payment as payment in full. The Outline of Coverage specifies that the beneficiary will pay “$0”, and the provider cannot balance bill the insured.
(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;
ayment as payment in full. The Outline of Coverage specifies that the beneficiary will pay “$0”, and the provider cannot balance bill the insured.
(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;
(5)	Coverage for the coinsurance amount (or in the case of hospital outpatient department services under a prospective payment system, the copayment amount) of Medicare Eligible Expenses under Part B regardless of hospital confinement, subject to the Medicare Part B deductible.
Drafting Note: In this context, copayment amount means the least of “copayment amount,” “beneficiary copayment amount,” and “hospital-elected reduced copayment amount” as those terms are used in applicable federal law and regulation. Provisions governing copayment for hospital outpatient department services under a prospective payment system apply to all Medicare supplement policies or certificates issued prior to and after the effective date of this payment system.
C.	Standards for Additional Benefits. The additional benefits included in Medicare Supplement Benefit Plans “B” through “J,” as provided by Section 9 of this Rule, shall be defined as follows:
(1)	Medicare Part A Deductible: Coverage for all of the Medicare Part A inpatient hospital deductible amount per benefit period.
(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.
(3)	Medicare Part B Deductible: Coverage for all of the Medicare Part B deductible amount per calendar year regardless of hospital confinement.
(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.
(3)	Medicare Part B Deductible: Coverage for all of the Medicare Part B deductible amount per calendar year regardless of hospital confinement.
(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.
(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.
(6)	Basic Outpatient Prescription Drug Benefit: Coverage for fifty percent (50%) of outpatient prescription drug charges, after a two hundred fifty dollar ($250) calendar year deductible, to a maximum of one thousand two hundred fifty dollars ($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.
(7)	Extended Outpatient Prescription Drug Benefit: Coverage for fifty percent (50%) of outpatient prescription drug charges, after a two hundred fifty dollar ($250) calendar year deductible to a maximum of three thousand dollars ($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.
ifty percent (50%) of outpatient prescription drug charges, after a two hundred fifty dollar ($250) calendar year deductible to a maximum of three thousand dollars ($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)	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 two hundred fifty dollars ($250), and a lifetime maximum benefit of fifty thousand dollars ($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.
(9)	Preventive Medical Care Benefit: Coverage for the following preventive health services not covered by Medicare:
a.	An annual clinical preventive medical history and physical examination that may include tests and services from Subparagraph (b) and patient education to address preventive health care measures;
b.	Preventive screening tests or preventive services, the selection and frequency of which is determined to be medically appropriate by the attending physician.
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 one hundred twenty dollars ($120) annually under this benefit
to be medically appropriate by the attending physician.
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 one hundred twenty dollars ($120) annually under this benefit. This benefit shall not include payment for any procedure covered by Medicare.
(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.
a.	For purposes of this benefit, the following definitions shall apply:
i.	“Activities of daily living” include, but are not limited to bathing, dressing, personal hygiene, transferring, eating, ambulating, assistance with drugs that are normally self-administered, and changing bandages or other dressings.
ii.	“Care provider” means a duly qualified or licensed home health aide or homemaker, personal care aide or nurse provided through a licensed home health care agency or referred by a licensed referral agency or licensed nurses registry.
iii.	“Home” shall mean any place used by the insured as a place of residence, provided that such place would qualify as a residence for home health care services covered by Medicare. A hospital or skilled nursing facility shall not be considered the insured’s place of residence.
iv.	“At-home recovery visit” means the period of a visit required to provide at home recovery care, without limit on the duration of the visit, except each consecutive 4 hours in a 24-hour period of services provided by a care provider is one visit.
b.	Coverage Requirements and Limitations.
i.	At-home recovery services provided must be primarily services which assist in activities of daily living.
ii
ecovery 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 4 hours in a 24-hour period of services provided by a care provider is one visit.
b.	Coverage Requirements and Limitations.
i.	At-home recovery services provided must be primarily services which assist in activities of daily living.
ii.	The insured’s attending physician must certify that the specific type and frequency of at-home recovery services are necessary because of a condition for which a home care plan of treatment was approved by Medicare.
iii.	Coverage is limited to:
I.	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.
II.	The actual charges for each visit up to a maximum reimbursement for forty dollars ($40) per visit.
III.	One thousand six hundred dollars ($1,600) per calendar year.
IV.	Seven (7) visits in any one week.
V.	Care furnished on a visiting basis in the insured’s home.
VI.	Services provided by a care provider as defined in this section.
VII.	At-home recovery visits while the insured is covered under the policy or certificate and not otherwise excluded.
VIII.	At-home recovery visits received during the period the insured is receiving Medicare approved home care services or no more than eight (8) weeks after the service date of the last Medicare approved home health care visit.
c.	Coverage is excluded for:
i.	Home care visits paid for by Medicare or other government programs; and
ii.	Care provided by family members, unpaid volunteers or providers who are not care providers.
D.	Standards for Plans K and L
s receiving Medicare approved home care services or no more than eight (8) weeks after the service date of the last Medicare approved home health care visit.
c.	Coverage is excluded for:
i.	Home care visits paid for by Medicare or other government programs; and
ii.	Care provided by family members, unpaid volunteers or providers who are not care providers.
D.	Standards for Plans K and L
(1)	Standardized Medicare supplement benefit plan “K” shall consist of the following:
a.	Coverage of 100% of the Part A hospital coinsurance amount for each day used from the 61st through the 90th day in any Medicare benefit period;
b.	Coverage of 100% of the Part A hospital coinsurance amount for each Medicare lifetime inpatient reserve day used from the 91st through the 150th day in any Medicare benefit period;
c.	Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 100% of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system (PPS) rate, or other appropriate Medicare standard of payment, subject to a lifetime maximum benefit of an additional 365 days. The provider shall accept the issuer’s payment as payment in full and may not bill the insured for any balance;
d.	Medicare Part A Deductible: Coverage for 50% of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in Subparagraph (j);
e.	Skilled Nursing Facility Care: Coverage for 50% of the coinsurance amount for each day used from the 21st day through the 100th day in a Medicare benefit period for post-hospital skilled nursing facility care eligible under Medicare Part A until the out-of-pocket limitation is met as described in Subparagraph (j);
f.	Hospice Care: Coverage for 50% of cost sharing for all Part A Medicare eligible expenses and respite care until the out-of-pocket limitation is met as described in Subparagraph (j);
g
through the 100th day in a Medicare benefit period for post-hospital skilled nursing facility care eligible under Medicare Part A until the out-of-pocket limitation is met as described in Subparagraph (j);
f.	Hospice Care: Coverage for 50% of cost sharing for all Part A Medicare eligible expenses and respite care until the out-of-pocket limitation is met as described in Subparagraph (j);
g.	Coverage for 50%, under Medicare Part A or B, of the reasonable cost of the first three (3) pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulations) unless replaced in accordance with federal regulations, until the out-of-pocket limitation is met as described in Subparagraph (j);
h.	Except for coverage provided in subparagraph (i) below, coverage for 50% of the cost sharing otherwise applicable under Medicare Part B after the policyholder pays the Part B deductible until the out-of-pocket limitation is met as described in Subparagraph (j) below;
i.	Coverage of 100% of the cost sharing for Medicare Part B preventive services after the policyholder pays the Part B deductible; and
j.	Coverage of 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, which was $4000 in 2006 and is indexed each year by the appropriate inflation adjustment specified by the Secretary of the U.S. Department of Health and Human Services.
le; and
j.	Coverage of 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, which was $4000 in 2006 and is indexed each year by the appropriate inflation adjustment specified by the Secretary of the U.S. Department of Health and Human Services.
(2)	Standardized Medicare supplement benefit plan “L” shall consist of the following:
a.	The benefits described in Paragraphs (1)(a), (b), (c), and (i);
b.	The benefit described in Paragraphs (1)(d), (e), (f), (g), and (h), but substituting 75% for 50%; and
c.	The benefit described in Paragraph (1)(j), but substituting $2000 for $4000.
Section 8.1	Benefit Standards for 2010 Standardized Medicare Supplement Benefit Plan
Policies or Certificates Issued for Delivery with an Effective Date of Coverage on or After June 1, 2010
The following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this State with an effective date of coverage on or after June 1, 2010. No policy or certificate may be advertised, solicited, delivered, or issued for delivery in this State as a Medicare supplement policy or certificate unless it complies with these benefit 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 with an effective date of coverage before June 1, 2010 remain subject to the requirements of Section 8.
A.	General Standards. The following standards apply to Medicare supplement policies and certificates and are in addition to all other requirements of this Rule.
benefit plan for sale on or after June 1, 2010. Benefit standards applicable to Medicare supplement policies and certificates issued with an effective date of coverage before June 1, 2010 remain subject to the requirements of Section 8.
A.	General Standards. The following standards apply to Medicare supplement policies and certificates and are in addition to all other requirements of this Rule.
(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.
(2) A Medicare supplement policy or certificate shall not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents.
(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.
(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.
incide with any changes in the applicable Medicare deductible, co-payment, or coinsurance amounts. Premiums may be modified to correspond with such changes.
(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.
(5) Each Medicare supplement policy shall be guaranteed renewable.
a.	The issuer shall not cancel or non-renew the policy on the ground of health status of the individual.
b.	The issuer shall not cancel or non-renew the policy for any reason other than nonpayment of premium or material misrepresentation.
c.	If the Medicare supplement policy is terminated by the group policyholder and is not replaced as provided under Section 8.1(A)(5)(e) of this Rule, the issuer shall offer each certificate holder an individual Medicare supplement policy which (at the option of the certificate holder):
i.	Provides for continuation of the benefits contained in the group policy; or
ii.	Provides for benefits that otherwise meet the requirements of this subsection.
d.	If an individual is a certificate holder in a group Medicare supplement policy and the individual terminates membership in the group, the issuer shall
i.	Offer the certificate holder the conversion opportunity described in Section 8.1(A)(5)(c) of this Rule; or
ii.	At the option of the group policyholder, offer the certificate holder continuation of coverage under the group policy.
e.	If a group Medicare supplement policy is replaced by another group Medicare supplement policy purchased by the same policyholder, the issuer of the replacement policy shall offer coverage to all persons covered under the old group policy on its date of termination. Coverage under the new policy shall not result in any exclusion for preexisting conditions that would have been covered under the group policy being replaced.
ement 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.
(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.
A carrier issuing a subsequent Medicare supplement policy may not deny any claim otherwise covered under the policy on the basis that the enrollee is entitled to an extension of coverage under a prior policy pursuant to this paragraph, unless the prior carrier has paid the claim or has agreed in writing that it is providing coverage for the claim. If the prior carrier does not agree in writing to provide coverage for the claim, any disputes over the carriers’ respective responsibilities for payment may be resolved in accordance with the procedures applicable to medical coverage as set forth in Bureau of Insurance Rule 790.
aph, unless the prior carrier has paid the claim or has agreed in writing that it is providing coverage for the claim. If the prior carrier does not agree in writing to provide coverage for the claim, any disputes over the carriers’ respective responsibilities for payment may be resolved in accordance with the procedures applicable to medical coverage as set forth in Bureau of Insurance Rule 790.
(7)	a.	A Medicare supplement policy or certificate shall provide that benefits and premiums under the policy or certificate shall be suspended at the request of the policyholder or certificate holder for the period (not to exceed twenty-four (24) months) in which the policyholder or certificate holder has applied for and is determined to be entitled to medical assistance under Title XIX of the Social Security Act, but only if the policyholder or certificate holder notifies the issuer of the policy or certificate within ninety (90) days after the date the individual becomes entitled to assistance.
b.	If suspension occurs and if the policyholder or certificate holder loses entitlement to medical assistance, the policy or certificate shall be automatically reinstituted, effective as of the date of termination of entitlement, 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 beginning on the date of termination of entitlement.
c.	Each Medicare supplement policy shall provide that benefits and premiums under the policy shall be suspended (for any period that may be provided by federal regulation) at the request of the policyholder if the policyholder is entitled to benefits under Section 226(b) of the Social Security Act and is covered under a group health plan (as defined in Section 1862(b)(1)(A)(v) of the Social Security Act)
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 and pays the premium attributable to the period beginning on the date of termination of enrollment in the group health plan.
d.	Reinstitution of coverages as described in Subparagraphs (b) and (c):
i.	Shall not provide for any waiting period with respect to treatment of preexisting conditions;
ii.	Shall provide for resumption of coverage that is substantially equivalent to coverage in effect before the date of suspension; and
iii.	Shall provide for classification of premiums on terms at least as favorable to the policyholder or certificate holder as the premium classification terms that would have applied to the policyholder or certificate holder had the coverage not been suspended.
B. 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 any of the other Medicare Supplement Insurance Benefit Plans available to prospective insureds, in addition to the basic core package, but not in lieu of it.
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 any of the other Medicare Supplement Insurance Benefit Plans available to prospective insureds, in addition to the basic core package, but not in lieu of it.
(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;
(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;
(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;
Drafting Note: The issuer is required to pay whatever amount Medicare would have paid as if Medicare was covering the hospitalization. The “or other appropriate Medicare standard of payment” provision means the manner in which Medicare would have paid. The issuer stands in the place of Medicare, and so the provider must accept the issuer’s payment as payment in full. The Outline of Coverage specifies that the beneficiary will pay “$0,” and the provider cannot balance bill the insured.
(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;
ayment as payment in full. The Outline of Coverage specifies that the beneficiary will pay “$0,” and the provider cannot balance bill the insured.
(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;
(5)	Coverage for the coinsurance amount, or in the case of hospital outpatient department services paid under a prospective payment system, the copayment amount, of Medicare eligible expenses under Part B regardless of hospital confinement, subject to the Medicare Part B deductible;
(6)	Hospice Care: Coverage of cost sharing for all Part A Medicare eligible hospice care and respite care expenses.
Drafting Note: In all cases involving hospital outpatient department services paid under a prospective payment system, the issuer is required to pay the co-payment amount established by CMS, which will be either the amount established for the Ambulatory Payment Classification (“APC”) group, or a provider-elected reduced co-payment amount.
C. 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 Section 9.1 of this Rule:
Drafting Note: Benefits for Plans K and L are set by The Medicare Prescription Drug, Improvement, and Modernization Act of 2003, and can be found in Sections 9.1(E)(8) and (9) of this Rule.
(1) Medicare Part A Deductible: Coverage for one hundred percent (100%) of the Medicare Part A inpatient hospital deductible amount per benefit period.
(2) Medicare Part A Deductible: Coverage for fifty percent (50%) of the Medicare Part A inpatient hospital deductible amount per benefit period.
ment, and Modernization Act of 2003, and can be found in Sections 9.1(E)(8) and (9) of this Rule.
(1) Medicare Part A Deductible: Coverage for one hundred percent (100%) of the Medicare Part A inpatient hospital deductible amount per benefit period.
(2) Medicare Part A Deductible: Coverage for fifty percent (50%) of the Medicare Part A inpatient hospital deductible amount per benefit period.
(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.
(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.
(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.
(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.
Drafting Note: The Omnibus Budget Reconciliation Act 1990, 42 U.S.C
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.
Drafting Note: The Omnibus Budget Reconciliation Act 1990, 42 U.S.C. § 1395ss(p)(7), does not prohibit the issuers of Medicare supplement policies, through an arrangement with a vendor for discounts from the vendor, from making available discounts from the vendor to the policyholder or certificate holder for the purchase of items or services not covered under its Medicare supplement policies (for example: discounts on hearing aids or eyeglasses).
Section 9.	Standard Medicare Supplement Benefit Plans for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or After January 1, 1992 and with an Effective Date of Coverage Prior to June 1, 2010
A.	An issuer shall make available to each prospective policyholder and certificate holder a policy form or certificate form containing only the basic core benefits, as defined in Section 8(B) of this Rule.
B.	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 Section 9(G) and in Section 10 of this Rule.
C.	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 of this Rule. Each benefit shall be structured in accordance with the format provided in Sections 8(B) and 8(C), or 8(D) and list the benefits in the order shown in this subsection. For purposes of this section, “structure, language, and format” includes style, arrangement, and overall content of a benefit.
D
“A” through “L” listed in this subsection and conform to the definitions in Section 4 of this Rule. Each benefit shall be structured in accordance with the format provided in Sections 8(B) and 8(C), or 8(D) and list the benefits in the order shown in this subsection. For purposes of this section, “structure, language, and format” includes style, arrangement, and overall content of a benefit.
D.	An issuer may use, in connection with the benefit plan designations required in Subsection C, supplementary designations such as trade names to the extent permitted by law.
E.	Make-up of benefit plans.
(1)	Standardized Medicare supplement benefit plan “A” shall be limited to the Basic (Core) Benefits Common to All Benefit Plans, as defined in Section 8(B) of this Rule.
(2)	Standardized Medicare supplement benefit plan “B” shall include only the following: The Core Benefit as defined in Section 8(B) of this Rule, plus the Medicare Part A Deductible as defined in Section 8(C)(1).
(3)	Standardized Medicare supplement benefit plan “C” shall include only the following: The Core Benefit as defined in Section 8(B) of this Rule, 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 Sections 8(C)(1), (2), (3), and (8) respectively.
(4)	Standardized Medicare supplement benefit plan “D” shall include only the following: The Core Benefits (as defined in Section 8(B) of this Rule), plus the Medicare Part A Deductible, Skilled Nursing Facility Care, Medically Necessary Emergency Care in a Foreign Country and the At-Home Recovery Benefit as defined in Sections 8(C)(1), (2), (8), and (10) respectively.
(3), and (8) respectively.
(4)	Standardized Medicare supplement benefit plan “D” shall include only the following: The Core Benefits (as defined in Section 8(B) of this Rule), plus the Medicare Part A Deductible, Skilled Nursing Facility Care, Medically Necessary Emergency Care in a Foreign Country and the At-Home Recovery Benefit as defined in Sections 8(C)(1), (2), (8), and (10) respectively.
(5)	Standardized Medicare supplement benefit plan “E” shall include only the following: The Core Benefit as defined in Section 8(B) of this Rule, 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 Sections 8(C)(1), (2), (8), and (9), respectively.
(6)	Standardized Medicare supplement benefit plan “F” shall include only the following: The Core Benefit as defined in Section 8(B) of this Rule, 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 Sections 8(C)(1), (2), (3), (5), and (8) respectively.
(7)	Standardized Medicare supplement high deductible benefit 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 Section 8(B) of this Rule, 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 Sections 8(C)(1), (2), (3), (5), and (8) 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
dicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in Sections 8(C)(1), (2), (3), (5), and (8) 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 $1530 for 2000, 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.
(8)	Standardized Medicare supplement benefit plan “G” shall include only the following: The core benefit as defined in Section 8(B) of this Rule, 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 Sections 8(C)(1), (2), (4), (8), and (10) respectively.
(9)	Standardized Medicare supplement benefit plan “H” shall consist of only the following: The core benefit as defined in Section 8(B) of this Rule, 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 Sections 8(C)(1), (2), (6), and (8) respectively. This plan shall not be sold after December 31, 2005.
upplement benefit plan “H” shall consist of only the following: The core benefit as defined in Section 8(B) of this Rule, 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 Sections 8(C)(1), (2), (6), and (8) respectively. This plan shall not be sold after December 31, 2005.
(10)	Standardized Medicare supplement benefit plan “I” shall consist of only the following: The core benefit as defined in Section 8(B) of this Rule, 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 Sections 8(C)(1), (2), (5), (6), (8), and (10) respectively. This plan shall not be sold after December 31, 2005.
(11)	Standardized Medicare supplement benefit plan “J” shall consist of only the following: The core benefit as defined in Section 8(B) of this Rule, 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 Sections 8(C)(1), (2), (3), (5), (7), (8), (9), and (10) respectively. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005.
0%) 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 Sections 8(C)(1), (2), (3), (5), (7), (8), (9), and (10) respectively. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005.
(12)	Standardized Medicare supplement high deductible benefit 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 Section 8(B) of this Rule, 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 Sections 8(C)(1), (2), (3), (5), (7), (8), (9), and (10) 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 $1530 for 2000, 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.
F.	Make-up of two Medicare supplement plans mandated by The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA);
or 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.
F.	Make-up of two Medicare supplement plans mandated by The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA);
(1)	Standardized Medicare supplement benefit plan “K” shall consist of only those benefits described in Section 8(D)(1).
(2)	Standardized Medicare supplement benefit plan “L” shall consist of only those benefits described in Section 8(D)(2).
G.	New or Innovative Benefits: An issuer may, with the prior approval of the Superintendent, 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 which 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.
Section 9.1	Standard Medicare Supplement Benefit Plans for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery with an Effective Date of Coverage on or After June 1, 2010
The following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this State with an effective date of coverage on or after June 1, 2010. No policy or certificate may be advertised, solicited, delivered, or issued for delivery in this State as a Medicare supplement policy or certificate unless it complies with these benefit plan standards
e following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this State with an effective date of coverage on or after June 1, 2010. No policy or certificate may be advertised, solicited, delivered, or issued for delivery in this State as a Medicare supplement policy or certificate unless it complies with these benefit plan standards. Benefit plan standards applicable to Medicare supplement policies and certificates issued with an effective date of coverage before June 1, 2010 remain subject to the requirements of Section 9.
A.	(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 Section 8.1(B) of this Rule.
(2)	If an issuer makes available any of the additional benefits described in Section 8.1(C), or offers standardized benefit Plans K or L (as described in Sections 9.1(E)(8) and (9) of this Rule), then the issuer shall make available to each prospective policyholder and certificate holder, in addition to a policy form or certificate form with only the basic (core) benefits as described in Subsection A(1) above, a policy form or certificate form containing either standardized benefit Plan C (as described in Section 9.1(E)(3) of this Rule) or standardized benefit Plan F (as described in 9.1(E)(5) of this Rule).
B. 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 Section 9.1(F) and in Section 10 of this Rule.
C.	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 of this Rule
r 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 Section 9.1(F) and in Section 10 of this Rule.
C.	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 of this Rule. Each benefit shall be structured in accordance with the format provided in Sections 8.1(B) and 8.1(C) of this Rule; or, in the case of plans K or L, in Sections 9.1(E)(8) or (9) of this Rule and list the benefits in the order shown. For purposes of this section, “structure, language, and format” means style, arrangement, and overall content of a benefit.
D.	In addition to the benefit plan designations required in Subsection C of this section, an issuer may use other designations to the extent permitted by law.
E. Make-up of 2010 Standardized Benefit Plans:
(1)	Standardized Medicare supplement benefit Plan A shall include only the following:
The basic (core) benefits as defined in Section 8.1(B) of this Rule.
(2)	Standardized Medicare supplement benefit Plan B shall include only the following:
The basic (core) benefit as defined in Section 8.1(B) of this Rule, plus one hundred percent (100%) of the Medicare Part A deductible as defined in Section 8.1(C)(1) of this Rule.
(3)	Standardized Medicare supplement benefit Plan C shall include only the following: The basic (core) benefit as defined in Section 8.1(B) of this Rule, 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 Sections 8.1(C)(1), (3), (4), and (6) of this Rule, respectively.
hall include only the following: The basic (core) benefit as defined in Section 8.1(B) of this Rule, 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 Sections 8.1(C)(1), (3), (4), and (6) of this Rule, respectively.
(4)	Standardized Medicare supplement benefit Plan D shall include only the following: The basic (core) benefit (as defined in Section 8.1(B) of this Rule), 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 Sections 8.1(C)(1), (3), and (6) of this Rule, respectively.
(5)	Standardized Medicare supplement [regular] benefit Plan F shall include only the following: The basic (core) benefit as defined in Section 8.1(B) of this Rule, 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 Sections 8.1(C)(1), (3), (4), (5), and (6) respectively.
(6)	Standardized Medicare supplement benefit 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 Subparagraph (b).
a.	The covered expenses (after the deductible) are: the basic (core) benefit as defined in Section 8.1(B) of this Rule, 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 Sections 8.1(C)(1), (3), (4), (5), and (6) of this Rule, respectively
n Section 8.1(B) of this Rule, 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 Sections 8.1(C)(1), (3), (4), (5), and (6) of this Rule, respectively.
b.	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).
(7)	Standardized Medicare supplement benefit Plan G shall include only the following: The basic (core) benefit as defined in Section 8.1(B) of this Rule, 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 Sections 8.1(C)(1), (3), (5), and (6), respectively. Effective January 1, 2020, the standardized benefit plans described in Section 9.2(A)(4) of this Rule (Redesignated Plan G High Deductible) may be offered to any individual who was eligible for Medicare prior to January 1, 2020.
00%) of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in Sections 8.1(C)(1), (3), (5), and (6), respectively. Effective January 1, 2020, the standardized benefit plans described in Section 9.2(A)(4) of this Rule (Redesignated Plan G High Deductible) may be offered to any individual who was eligible for Medicare prior to January 1, 2020.
(8)	Standardized Medicare supplement benefit Plan K is mandated by The Medicare Prescription Drug, Improvement and Modernization Act of 2003, and shall include only the following:
a.	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 61st through the 90th day in any Medicare benefit period;
b.	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;
c.	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. The provider shall accept the issuer’s payment as payment in full and may not bill the insured for any balance;
d.	Medicare Part A Deductible: Coverage for fifty percent (50%) of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in Subparagraph (j);
e
ect to a lifetime maximum benefit of an additional 365 days. The provider shall accept the issuer’s payment as payment in full and may not bill the insured for any balance;
d.	Medicare Part A Deductible: Coverage for fifty percent (50%) of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in Subparagraph (j);
e.	Skilled Nursing Facility Care: Coverage for fifty percent (50%) of the coinsurance amount for each day used from the 21st day through the 100th day in a Medicare benefit period for post-hospital skilled nursing facility care eligible under Medicare Part A until the out-of-pocket limitation is met as described in Subparagraph (j);
f.	Hospice Care: Coverage for fifty percent (50%) of cost sharing for all Part A Medicare eligible expenses and respite care until the out of- pocket limitation is met as described in Subparagraph (j);
g.	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 Subparagraph (j);
h.	Part B Cost Sharing: Except for coverage provided in Subparagraph (i), coverage for fifty percent (50%) of the cost sharing otherwise applicable under Medicare Part B after the policyholder pays the Part B deductible until the out-of-pocket limitation is met as described in Subparagraph (j);
i.	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
j
ifty percent (50%) of the cost sharing otherwise applicable under Medicare Part B after the policyholder pays the Part B deductible until the out-of-pocket limitation is met as described in Subparagraph (j);
i.	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
j.	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, which was $4000 in 2006 and is indexed each year by the appropriate inflation adjustment specified by the Secretary of the U.S. Department of Health and Human Services.
(9)	Standardized Medicare supplement benefit Plan L is mandated by The Medicare Prescription Drug, Improvement, and Modernization Act of 2003, and shall include only the following:
a.	The benefits described in Paragraphs 9.1(E)(8)(a), (b), (c), and (i);
b.	The benefit described in Paragraphs 9.1(E)(8)(d), (e), (f), (g), and (h), but substituting seventy-five percent (75%) for fifty percent (50%); and
c.	The benefit described in Paragraph 9.1(E)(8)(j), but substituting $2000 for $4000.
(10)	Standardized Medicare supplement benefit Plan M shall include only the following: The basic (core) benefit as defined in Section 8.1(B) of this Rule, 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 Sections 8.1(C)(2), (3), and (6) of this Rule, respectively.
$2000 for $4000.
(10)	Standardized Medicare supplement benefit Plan M shall include only the following: The basic (core) benefit as defined in Section 8.1(B) of this Rule, 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 Sections 8.1(C)(2), (3), and (6) of this Rule, respectively.
(11)	Standardized Medicare supplement benefit Plan N shall include only the following: The basic (core) benefit as defined in Section 8.1(B) of this Rule, 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 Sections 8.1(C)(1), (3), and (6) of this Rule, respectively, with copayments in the following amounts:
a.	The lesser of twenty dollars ($20) or the Medicare Part B coinsurance or copayment for each covered health care provider office visit (including visits to medical specialists); and
b.	The lesser of fifty dollars ($50) or the Medicare Part B coinsurance or copayment for each covered emergency room visit, however, this copayment shall be waived if the insured is admitted to any hospital and the emergency visit is subsequently covered as a Medicare Part A expense.
F.	New or Innovative Benefits: An issuer may, with the prior approval of the Superintendent, 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. 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
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. 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.
Section 9.2	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.
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires the following standards to apply 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 Section 9.1.
A.	Benefit Requirements. The standards and requirements of Section 9.1 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:
tificates issued to individuals eligible for Medicare before January 1, 2020, remain subject to the requirements of Section 9.1.
A.	Benefit Requirements. The standards and requirements of Section 9.1 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:
(1)	Standardized Medicare supplement benefit Plan C is redesignated as Plan D and shall provide the benefits contained in Section 9.1(E)(3) of this Rule but shall not provide coverage for one hundred percent (100%) or any portion of the Medicare Part B deductible.
(2)	Standardized Medicare supplement benefit Plan F is redesignated as Plan G and shall provide the benefits contained in Section 9.1(E)(5) of this Rule but shall not provide coverage for one hundred percent (100%) or any portion of the Medicare Part B deductible.
(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.
(4)	Standardized Medicare supplement benefit Plan F with High Deductible is redesignated as Plan G with High Deductible and shall provide the benefits contained in Section 9.1(E)(6) of this Rule 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 Plan’s annual high deductible.
Drafting Note: Subsection A(4), above, implements the High Deductible Plan G as a redesignation of the prior High Deductible Plan F because federal law “deems” any reference to Plan F to be a reference to Plan G for “newly eligible” Medicare beneficiaries
e Medicare Part B deductible paid by the beneficiary shall be considered an out-of-pocket expense in meeting the Plan’s annual high deductible.
Drafting Note: Subsection A(4), above, implements the High Deductible Plan G as a redesignation of the prior High Deductible Plan F because federal law “deems” any reference to Plan F to be a reference to Plan G for “newly eligible” Medicare beneficiaries. High Deductible Plan G is the same as High Deductible Plan F except that where the annual out-of-pocket expenses are met with Medicare Part A expenses only, any subsequent Medicare Part B deductible expense incurred by the beneficiary after the required annual out-of-pocket expenses is met may not be paid for by High Deductible Plan G. Federal law prohibits the sale or issuance of any Medicare supplement policy that provides coverage of the Part B deductible to a “newly eligible” Medicare beneficiary and was enacted for the purpose of increasing cost-sharing and reducing “first dollar coverage.” High Deductible plans meet this purpose. A beneficiary buying such a plan has a reasonable expectation that the plan will begin providing coverage after the beneficiary has paid the stated dollar amount in full, so making the beneficiary satisfy two separate deductible requirements on a cumulative basis would be a misleading description of the terms of the plan.
(5)	The reference to Plans C or F contained in Section 9.1(A)(2) is deemed a reference to Plans D or G for purposes of this section.
B.	Applicability to Certain Individuals. This Section 9.2 applies only to individuals who are newly eligible for Medicare on or after January 1, 2020:
(1)	By reason of attaining age 65 on or after January 1, 2020; or
misleading description of the terms of the plan.
(5)	The reference to Plans C or F contained in Section 9.1(A)(2) is deemed a reference to Plans D or G for purposes of this section.
B.	Applicability to Certain Individuals. This Section 9.2 applies only to individuals who are newly eligible for Medicare on or after January 1, 2020:
(1)	By reason of attaining age 65 on or after January 1, 2020; or
(2)	By reason of entitlement to benefits under part A 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.
C.	Offer of Redesignated Plans to Individuals Other Than Newly Eligible. On or after January 1, 2020, the standardized benefit plans described in subparagraph A(4) above may be offered to any individual who was eligible for Medicare prior to January 1, 2020 in addition to the standardized plans described in section 9.1(E) of this Rule.
Drafting Note: The standardized benefit plans described in subparagraphs A(1) and A(2) above in this Section are also included as benefit plans D and G in Section 9.1(E)(4) and (7).
Section 10.	Medicare Select Policies and Certificates
A.	(1)	This section shall apply to Medicare Select policies and certificates, as defined in this section.
(2)	No policy or certificate may be advertised as a Medicare Select policy or certificate unless it meets the requirements of this section.
B.	For the purposes of this section:
(1)	“Complaint” means any dissatisfaction expressed by an individual concerning a Medicare Select issuer or its network providers.
(2)	“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.
(3)	“Medicare Select Issuer” means an issuer offering, or seeking to offer, a Medicare Select policy or certificate.
network providers.
(2)	“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.
(3)	“Medicare Select Issuer” means an issuer offering, or seeking to offer, a Medicare Select policy or certificate.
(4)	“Medicare Select Policy” and “Medicare Select Certificate” mean respectively a Medicare supplement policy or certificate that contains restricted network provisions.
(5)	“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.
(6)	“Restricted Network Provision” means any provision which conditions the payment of benefits, in whole or in part, on the use of network providers.
(7)	“Service Area” means the geographic area approved by the Superintendent within which an issuer is authorized to offer a Medicare Select policy.
C.	The Superintendent 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 Superintendent finds that the issuer has satisfied all of the requirements of this Rule.
D.	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 Superintendent.
E.	A Medicare Select issuer shall file a proposed plan of operation with the Superintendent in a format prescribed by the Superintendent. The plan of operation shall contain at least the following information:
ements of this Rule.
D.	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 Superintendent.
E.	A Medicare Select issuer shall file a proposed plan of operation with the Superintendent in a format prescribed by the Superintendent. The plan of operation shall contain at least the following information:
(1)	Evidence that all covered services that are subject to restricted network provisions are available and accessible through network providers, including a demonstration that:
a.	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.
b.	The number of network providers in the service area is sufficient, with respect to current and expected policyholders, either:
i.	To deliver adequately all services that are subject to a restricted network provision; or
ii.	To make appropriate referrals.
c.	There are written agreements with network providers describing specific responsibilities.
d.	Emergency care is available twenty-four (24) hours per day and seven (7) days per week.
e.	In the case of covered services that are 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 paragraph shall not apply to supplemental charges or coinsurance amounts as stated in the Medicare Select policy or certificate.
(2)	A statement or map providing a clear description of the service area.
(3)	A description of the grievance procedure to be utilized.
otherwise seeking reimbursement from or recourse against any individual insured under a Medicare Select policy or certificate. This paragraph shall not apply to supplemental charges or coinsurance amounts as stated in the Medicare Select policy or certificate.
(2)	A statement or map providing a clear description of the service area.
(3)	A description of the grievance procedure to be utilized.
(4)	A description of the quality assurance program, including:
a.	The formal organizational structure;
b.	The written criteria for selection, retention, and removal of network providers; and
c.	The procedures for evaluating quality of care provided by network providers, and the process to initiate corrective action when warranted.
(5)	A list and description, by specialty, of the network providers.
(6)	Copies of the written information proposed to be used by the issuer to comply with Subsection I.
(7)	Any other information requested by the Superintendent.
F.	(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 Superintendent prior to implementing such changes. Such changes shall be considered approved by the Superintendent after thirty (30) days unless specifically disapproved.
(2)	An updated list of network providers shall be filed with the Superintendent at least quarterly.
G.	A Medicare Select policy or certificate shall not restrict payment for covered services provided by non-network providers if:
(1)	The services are for symptoms requiring emergency care or are immediately required for an unforeseen illness, injury or a condition; and
specifically disapproved.
(2)	An updated list of network providers shall be filed with the Superintendent at least quarterly.
G.	A Medicare Select policy or certificate shall not restrict payment for covered services provided by non-network providers if:
(1)	The services are for symptoms requiring emergency care or are immediately required for an unforeseen illness, injury or a condition; and
(2)	It is not reasonable to obtain such services through a network provider.
H.	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.
I.	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:
(1)	An outline of coverage sufficient to permit the applicant to compare the coverage and premiums of the Medicare Select policy or certificate with:
a.	Other Medicare supplement policies or certificates offered by the issuer; and
b.	Other Medicare Select policies or certificates.
(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.
(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.
(4)	A description of coverage for emergency and urgently needed care and other out-of-service area coverage.
(5)	A description of limitations on referrals to restricted network providers and to other providers.
o 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.
(4)	A description of coverage for emergency and urgently needed care and other out-of-service area coverage.
(5)	A description of limitations on referrals to restricted network providers and to other providers.
(6)	A description of the policyholder’s rights to purchase any other Medicare supplement policy or certificate otherwise offered by the issuer.
(7)	A description of the Medicare Select issuer’s quality assurance program and grievance procedure.
J.	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 I of this section and that the applicant understands the restrictions of the Medicare Select policy or certificate.
K.	A Medicare Select issuer shall have and use procedures for hearing complaints and resolving written grievances from the subscribers. Such procedures shall be aimed at mutual agreement for settlement and may include arbitration procedures.
(1)	The grievance procedure shall be described in the policy and certificates and in the outline of coverage.
(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.
(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.
(4)	If a grievance is found to be valid, corrective action shall be taken promptly.
(5)	All concerned parties shall be notified about the results of a grievance.
grievance may be registered with the issuer.
(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.
(4)	If a grievance is found to be valid, corrective action shall be taken promptly.
(5)	All concerned parties shall be notified about the results of a grievance.
(6)	The issuer shall report no later than each March 31st to the Superintendent regarding its grievance procedure. The report shall be in a format prescribed by the Superintendent and shall contain the number of grievances filed in the past year and a summary of the subject, nature and resolution of such grievances.
L.	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.
M.	(1)	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.
dividual 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.
(2)	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 paragraph, a significant benefit means coverage for the Medicare Part A deductible, coverage for at-home recovery services or coverage for Part B excess charges.
N.	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.
(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 such policies and certificates available without requiring evidence of insurability.
uer 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 such policies and certificates available without requiring evidence of insurability.
(2)	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 paragraph, a significant benefit means coverage for the Medicare Part A deductible, coverage for at-home recovery services or coverage for Part B excess charges.
O.	A Medicare Select issuer shall comply with reasonable requests for data made by state or federal agencies, including the United States Department of Health and Human Services, for the purpose of evaluating the Medicare Select Program.
Section 11.	Open Enrollment
A.	Each Medicare beneficiary shall be entitled to a 6-month open enrollment period beginning on the date he or she first enrolls for benefits under Medicare Part B, and each individual enrolled for benefits under Medicare Part B before turning 65 shall be entitled to an additional 6-month open enrollment period beginning on his or her 65th birthday. An issuer shall not deny or condition the issuance or effectiveness of any Medicare supplement policy or certificate available for sale in this State, nor discriminate in the pricing of such a policy or certificate because of the applicant’s health status, claims experience, receipt of health care, or medical condition, if the application date falls during the applicant’s open enrollment period or during the preceding 60 days
ondition the issuance or effectiveness of any Medicare supplement policy or certificate available for sale in this State, nor discriminate in the pricing of such a policy or certificate because of the applicant’s health status, claims experience, receipt of health care, or medical condition, if the application date falls during the applicant’s open enrollment period or during the preceding 60 days. In the case of an application preceding the open enrollment period, the issuer may defer the effective date of the Medicare supplement policy until the first day of the open enrollment period. Each Medicare supplement policy and certificate currently available from an issuer shall be made available to all applicants who qualify under this subsection without regard to age.
B.	(1)	If an applicant qualifies under Subsection A and submits an application during the time period referenced in Subsection A and, as of the date of application, has had a continuous period of creditable coverage of at least six (6) months, the issuer shall not exclude benefits based on a preexisting condition.
(2)	If the applicant qualifies under Subsection A and submits an application during the time period referenced in Subsection A and, as of the date of application, has had a continuous period of creditable coverage that is less than six (6) months, the issuer shall reduce the period of any preexisting condition exclusion by the aggregate of the period of creditable coverage applicable to the applicant as of the enrollment date. For example, if a beneficiary did not have creditable coverage prior to enrolling in Medicare Part A and Part B at age 65 and then purchases a Medicare supplement policy with a six-month preexisting condition exclusion at month 5 of the open enrollment period, the preexisting condition exclusion period must be reduced to one month because Medicare is creditable coverage
as of the enrollment date. For example, if a beneficiary did not have creditable coverage prior to enrolling in Medicare Part A and Part B at age 65 and then purchases a Medicare supplement policy with a six-month preexisting condition exclusion at month 5 of the open enrollment period, the preexisting condition exclusion period must be reduced to one month because Medicare is creditable coverage. This example pertains only to Subsections A and B and does not preclude the insurer from underwriting or refusing to issue a policy if the insured does not elect a Medicare supplement policy during the 6-month period described in Subsection A or is otherwise provided for in Subsection B and Sections 12 and 23.
C.	Except as provided in Subsection B and Sections 12 and 23, Subsection A shall not be construed as preventing the exclusion of benefits under a policy, during the first six (6) months, based on a preexisting condition for which the policyholder or certificate holder received treatment or was otherwise diagnosed during the six (6) months before the coverage became effective.
Section 12.	Guaranteed Issue for Eligible Persons
A.	Guaranteed Issue
(1)	Eligible persons are those individuals described in Subsection B who apply to enroll under the policy not later than ninety (90) days after the date of the termination of enrollment described in Subsection B, and who submit evidence of the date of termination, disenrollment, or Medicare Part D enrollment with the application for a Medicare supplement policy, or within a reasonable time after the date of the application. In case of an individual described in Subsection 12(B)(1), the guaranteed issue period begins on the later of: (i) the date the individual receives a notice of termination or cessation of some or all supplemental health benefits (or if a notice is not received, notice that a claim has been denied because of such a termination or cessation); or (ii) the date that the applicable coverage terminates or ceases; and ends 90 days thereafter.
ubsection 12(B)(1), the guaranteed issue period begins on the later of: (i) the date the individual receives a notice of termination or cessation of some or all supplemental health benefits (or if a notice is not received, notice that a claim has been denied because of such a termination or cessation); or (ii) the date that the applicable coverage terminates or ceases; and ends 90 days thereafter.
(2)	With respect to eligible persons, an issuer shall not deny or condition the issuance or effectiveness of a Medicare supplement policy described in Subsection C that is offered and is available for issuance to new enrollees by the issuer, shall not discriminate in the pricing of such a Medicare supplement policy because of health status, claims experience, receipt of health care, or medical condition, and shall not impose an exclusion of benefits based on a preexisting condition under such a Medicare supplement policy. In the case of an individual applying for such a Medicare supplement policy within the 60 days before the anticipated date of termination of prior coverage, the issuer involved shall accept the application, but the coverage shall only become effective upon termination of the prior coverage. In the case of an individual applying for such a Medicare supplement policy who is not enrolled in Medicare Part B, the issuer may defer the effective date of the Medicare supplement policy until such time as the individual is enrolled in Medicare Part B.
B.	Eligible Persons
An eligible person is an individual described in any of the following paragraphs:
(1)	The individual is eligible for Medicare Part B and is enrolled under an employee welfare benefit plan and the plan terminates, or the plan ceases to provide some or all benefits that supplement the benefits under Medicare to the individual, or the plan ceases to provide health benefits to the individual because the individual leaves the plan;
idual described in any of the following paragraphs:
(1)	The individual is eligible for Medicare Part B and is enrolled under an employee welfare benefit plan and the plan terminates, or the plan ceases to provide some or all benefits that supplement the benefits under Medicare to the individual, or the plan ceases to provide health benefits to the individual because the individual leaves the plan;
(2)	The individual is enrolled with a Medicare Advantage organization under a Medicare Advantage plan under Part C of Medicare, and any of the following circumstances apply, or the individual is enrolled with a Program of All-Inclusive Care for the Elderly (PACE) provider under Section 1894 of the Social Security Act, and there are circumstances similar to those described below that would permit discontinuance of the individual’s enrollment with such provider if the individual were enrolled in a Medicare Advantage plan:
a.	The certification of the organization or plan under Part C has been terminated, or the organization has terminated or otherwise discontinued providing the plan in the area in which the individual resides;
b.	The individual has voluntarily disenrolled after receiving notice from the organization or plan or from the federal Health Care Finance Administration that the organization’s or plan’s certification will be terminated or the organization will terminate or discontinue the plan in the area in which the individual resides;
c.	The individual is no longer eligible to elect the plan because of a change in the individual’s place of residence or other change in circumstances specified by the Secretary, but not including termination of the individual’s enrollment on the basis described in Section 1851(g)(3)(B) of the federal Social Security Act (where the individual has not paid premiums on a timely basis or has engaged in disruptive behavior as specified in standards under Section 1856), or the plan is terminated for all individuals within a residence area;
d
mstances specified by the Secretary, but not including termination of the individual’s enrollment on the basis described in Section 1851(g)(3)(B) of the federal Social Security Act (where the individual has not paid premiums on a timely basis or has engaged in disruptive behavior

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Source: Frix Law Library, https://www.frixlaw.com/law-library/statutes/STATE_ME_CMR_00_031_275. Check the current official text before relying on it. Not legal advice.