# Ohio Admin. Code 3901-8-08: Rule 3901-8-08. Medicare supplement

> Ohio · Regulations · In force

URL: https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_3901_8_08

## Section

- **Citation:** Ohio Admin. Code 3901-8-08
- **Heading:** Rule 3901-8-08. Medicare supplement
- **Jurisdiction:** Ohio
- **Kind:** Regulations
- **Status:** In force
- **Text as of:** August 14, 2026
- **Source:** Compiled text
- **Location:** Ohio Administrative Code / Agency 3901 / Chapter 3901-8 / Rule 3901-8-08

## Text

119.03 (A) 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 sickness and accident insurance coverage to persons eligible for medicare. (B) Authority This rule is promulgated pursuant to the authority vested in the superintendent under sections 3901.041 , 3923.33 and 3923.331 to 3923.339 of the Revised Code. (C) Applicability and scope (1) Except as otherwise specifically provided in paragraphs (G), (P), (Q), (T), and (Y) of this rule, this rule applies to: (a) All medicare supplement policies, delivered or issued for delivery in this state on or after the effective date of this rule; and (b) All certificates issued under group medicare supplement policies which certificates have been delivered or issued for delivery in this state on or after the effective date of this rule. (2) This rule does not apply to a policy or contract of one or more employers or labor organizations, or of the trustees of a fund established by one or more employers or labor organizations, or combination thereof, for employees or former employees, or a combination thereof, or for members or former members, or a combination thereof, of the labor organizations. (D) Definitions For purposes of this rule, the following terms are defined as follows: (1) "Applicant" means, in the case of an individual medicare supplement policy, the person who seeks to contract for insurance benefits, and in the case of a group medicare supplement policy, the proposed certificate holder
, or for members or former members, or a combination thereof, of the labor organizations. (D) Definitions For purposes of this rule, the following terms are defined as follows: (1) "Applicant" means, in the case of an individual medicare supplement policy, the person who seeks to contract for insurance benefits, and in the case of a group medicare supplement policy, the proposed certificate holder. (2) "Bankruptcy" means when a "Medicare Advantage" organization that is not an issuer has filed, or has had filed against it, a petition for declaration of bankruptcy and has ceased doing business in the state. (3) "Certificate" means any certificate delivered or issued for delivery in this state under a group medicare supplement policy. (4) "Certificate form" means the form on which the certificate is delivered or issued for delivery by the issuer. (5) "Continuous period of creditable coverage" means the period during which an individual was covered by creditable coverage, if during the period of the coverage the individual had no breaks in coverage greater than sixty-three days. (6) (a) "Creditable coverage" means, with respect to an individual, coverage of the individual provided under any of the following: (i) A group health plan; (ii) Health insurance coverage; (iii) "Part A" or "Part B" of "Title XVIII of the Social Security Act" (medicare); (iv) "Title XIX of the Social Security Act" (medicaid), other than coverage consisting solely of benefits under section 1928; (v) "Chapter 55 of Title 10 United States Code (CHAMPUS)"; (vi) A medical care program of the Indian health service or of a tribal organization; (vii) A state health benefits risk pool; (viii) A health plan offered under chapter 89 of "Title 5 United States Code" (federal employees health benefits program); (ix) A public health plan as defined in federal regulation; and (x) A health benefit plan under section 5(e) of the "Peace Corps Act (22 United States Code" 2504(e))
care program of the Indian health service or of a tribal organization; (vii) A state health benefits risk pool; (viii) A health plan offered under chapter 89 of "Title 5 United States Code" (federal employees health benefits program); (ix) A public health plan as defined in federal regulation; and (x) A health benefit plan under section 5(e) of the "Peace Corps Act (22 United States Code" 2504(e)). (b) "Creditable coverage" does not include one or more, or any combination of, the following: (i) Coverage only for accident or disability income insurance, or any combination thereof; (ii) Coverage issued as a supplement to liability insurance; (iii) Liability insurance, including general liability insurance and automobile liability insurance; (iv) Workers' compensation or similar insurance; (v) Automobile medical payment insurance; (vi) Credit-only insurance; (vii) Coverage for on-site medical clinics; and (viii) Other similar insurance coverage, specified in federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits. (c) "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; (i) Limited scope dental or vision benefits; (ii) Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; and (iii) Such other similar, limited benefits as are specified in federal regulations. (d) "Creditable coverage" shall not include the following benefits if offered as independent, noncoordinated benefits: (i) Coverage only for a specified disease or illness; and (ii) Hospital indemnity or other fixed indemnity insurance
me care, home health care, community-based care, or any combination thereof; and (iii) Such other similar, limited benefits as are specified in federal regulations. (d) "Creditable coverage" shall not include the following benefits if offered as independent, noncoordinated benefits: (i) Coverage only for a specified disease or illness; and (ii) Hospital indemnity or other fixed indemnity insurance. (e) "Creditable coverage" shall not include the following if it is offered as a separate policy, certificate or contract of insurance: (i) Medicare supplemental health insurance as defined under section 1882(g)(1) of the "Social Security Act"; (ii) Coverage supplemental to the coverage provided under chapter 55 of "Title 10, United States Code"; and (iii) Similar supplemental coverage provided to coverage under a group health plan. (7) "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"). (8) "Insolvency" or "Insolvent" means: (a) For any issuer, that it is unable to pay its obligations when they are due, or when its admitted assets do not exceed its liabilities plus the greater of either of the following: (i) Any capital and surplus required by law for its organization; (ii) The total par or stated value of its authorized and issued capital stock. (b) As to any issuer licensed to do business in this state as of the effective date of sections 3903.01 to 3903.59 of the Revised Code that does not meet the standard established under paragraph (D)(8)(a) of this rule, the term "insolvency" or "insolvent" means, for a period not to exceed three years from the effective date of sections 3903.01 to 3903.59 of the Revised Code, that it is unable to pay its obligations when they are due or that its admitted assets do not exceed its liabilities plus any required capital contribution ordered by the superintendent under provisions of "Title XXXIX" of the Revised Code
, the term "insolvency" or "insolvent" means, for a period not to exceed three years from the effective date of sections 3903.01 to 3903.59 of the Revised Code, that it is unable to pay its obligations when they are due or that its admitted assets do not exceed its liabilities plus any required capital contribution ordered by the superintendent under provisions of "Title XXXIX" of the Revised Code. (c) For purposes of paragraph (D)(8) of this rule, "liabilities" includes, but is not limited to, reserves required by statute or by rules of the superintendent or specific requirements imposed by the superintendent upon a subject issuer at the time of admission or subsequent thereto. (9) "Direct response issuer" means an issuer who markets medicare supplement policies or certificates without the direct involvement of an insurance agent. (10) "Issuer" includes insurance companies, fraternal benefit societies, health care service plans health insuring corporations, and any other entities delivering or issuing for delivery in this state medicare supplement policies or certificates. (11) "Medicare" means the "Health Insurance for the Aged Act," "Title XVIII of the Social Security Amendments" of 1965, as then constituted or later amended. (12) "Medicare Advantage" plan means a plan of coverage for health benefits under medicare "Part C" as defined in 42 U.S.C. 1395w-28(b)(1), and includes: (a) Coordinated care plans which provide health care services, including but not limited to health insuring corporation plans (with or without a point-of-service option), plans offered by provider-sponsored organizations, and preferred provider organization plans; (b) Medical savings account plans coupled with a contribution into a "Medicare Advantage" medical savings account; and (c) "Medicare Advantage" private fee-for-service plans
de health care services, including but not limited to health insuring corporation plans (with or without a point-of-service option), plans offered by provider-sponsored organizations, and preferred provider organization plans; (b) Medical savings account plans coupled with a contribution into a "Medicare Advantage" medical savings account; and (c) "Medicare Advantage" private fee-for-service plans. (13) "Medicare supplement policy" means a group or individual policy of sickness and accident insurance or a subscriber contract of hospital and medical service associations or health insuring corporations, other than a policy issued pursuant to a contract under section 1876 of the federal "Social Security Act" (42 U.S.C. section 1395 et. seq.) or an issued policy under a demonstration project specified in 42 U.S.C. 1395 ss (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 section 1833(a)(1)(A) of the "Social Security Act". (14) "Pre-Standardized Medicare supplement benefit plan," "Pre-Standardized benefit plan" or "Pre-Standardized plan" means a group or individual policy of medicare supplement insurance issued prior to May 1, 1992. (15) "1990 Standardized Medicare supplement benefit plan," "1990 Standardized benefit plan" or "1990 plan" means a group or individual policy of medicare supplement insurance issued on or after May 1, 1992 and with an effective date for 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
supplement benefit plan," "1990 Standardized benefit plan" or "1990 plan" means a group or individual policy of medicare supplement insurance issued on or after May 1, 1992 and with an effective date for 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. (16) "2010 Standardized Medicare supplement benefit plan," "2010 Standardized benefit plan" or "2010 plan" means a group or individual policy of medicare supplement insurance with an effective date for coverage on or after June 1, 2010. (17) "Policy form" means the form on which the policy is delivered or issued for delivery by the issuer. (18) "Secretary" means the secretary of the "United States" department of health and human services. (E) 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 paragraph (E) of this rule. (1) "Accident," "accidental injury," or "accidental means" shall be defined to employ "result" language and shall not include words which would establish an accidental means test or use words such as "external, violent, visible wounds" or similar words of description or characterization. (a) The definition shall not be more restrictive than the following: "Injury or injuries for which benefits are provided means accidental bodily injury sustained by the insured person which is the direct result of an accident, independent of disease or bodily infirmity or any other cause, and occurs while insurance coverage is in force." (b) The definition may provide that the injuries shall not include injuries for which benefits are provided or available under any workers' compensation, employer's liability or similar law, or motor vehicle no-fault plan, unless prohibited by law
ch 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." (b) The definition may provide that the injuries shall not include injuries for which benefits are provided or available under any workers' compensation, employer's liability or similar law, or motor vehicle no-fault plan, unless prohibited by law. (2) "Benefit period" or "medicare benefit period" shall not be defined more restrictively than as defined in the medicare program. (3) "Convalescent nursing home," "extended care facility," or "skilled nursing facility" shall not be defined more restrictively than as defined in the medicare program. (4) "Health care expenses" means, for purposes of paragraph (Q) of this rule, expenses of health insuring corporations associated with the delivery of health care services, which expenses are analogous to incurred losses of insurers. (5) "Hospital" may be defined in relation to its status, facilities and available services or to reflect its accreditation by the "Joint Commission on Accreditation of Hospitals," but not more restrictively than as defined in the medicare program. (6) "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. (7) "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. (8) "Physician" shall not be defined more restrictively than as defined in the medicare program
urance for the Aged Act, as then constituted and any later amendments or substitutes thereof," or words of similar import. (7) "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. (8) "Physician" shall not be defined more restrictively than as defined in the medicare program. (9) "Sickness" shall not be defined to be more restrictive than the following: "Sickness" means illness or disease of an insured person which first manifests itself after the effective date of insurance and while the insurance is in force. The definition may be further modified to exclude sicknesses or diseases for which benefits are provided under any workers' compensation, occupational disease, employer's liability or similar law. (F) Policy provisions (1) Except for permitted preexisting condition clauses as described in paragraphs (G)(1)(a), (H)(1)(a), and (I)(1)(a) 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. (2) No medicare supplement policy or certificate may use waivers to exclude, limit or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions. (3) No medicare supplement policy or certificate in force in this state shall contain benefits which duplicate benefits provided by medicare. (4) (a) Subject to paragraphs (G)(1)(d), (G)(1)(e), (G)(1)(g), (H)(1)(d) and (H)(1)(e) 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. (b) A medicare supplement policy with benefits for outpatient prescription drugs shall not be issued after December 31, 2005
e), (G)(1)(g), (H)(1)(d) and (H)(1)(e) 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. (b) A medicare supplement policy with benefits for outpatient prescription drugs shall not be issued after December 31, 2005. (c) 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: (i) 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; (ii) 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. (G) Minimum benefit standards for pre-standardized medicare supplement benefit plan policies or certificates issued for delivery prior to May 1, 1992. No policy or certificate may be advertised, solicited or issued for delivery in this state prior to the effective date of this rule as a medicare supplement policy or certificate unless it meets or exceeds the following minimum standards. These are minimum standards and do not preclude the inclusion of other provisions or benefits which are not inconsistent with these standards. (1) General standards. The following standards apply to medicare supplement policies and certificates and are in addition to all other requirements of this rule. (a) A medicare supplement policy or certificate shall not exclude or limit benefits for losses incurred more than six months from the effective date of coverage because they involved a preexisting condition
onsistent with these standards. (1) General standards. The following standards apply to medicare supplement policies and certificates and are in addition to all other requirements of this rule. (a) A medicare supplement policy or certificate shall not exclude or limit benefits for losses incurred more than six months from the effective date of coverage because they involved a preexisting condition. The policy or certificate shall not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within six months before the effective date of coverage. (b) A medicare supplement policy or certificate shall not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents. (c) 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. (d) A "noncancellable," "guaranteed renewable," or "noncancellable and guaranteed renewable" medicare supplement policy shall not: (i) Provide for termination of coverage of a spouse solely because of the occurrence of an event specified for termination of coverage of the insured, other than the nonpayment of premium; or (ii) Be cancelled or nonrenewed by the issuer solely on the grounds of deterioration of health. (e) (i) Except as authorized by the superintendent, an issuer shall neither cancel nor nonrenew a medicare supplement policy or certificate for any reason other than nonpayment of premium or material misrepresentation. (ii) If a group medicare supplement insurance policy is terminated by the group policyholder and not replaced as provided in paragraph (G)(1)(e)(iv) of this rule, the issuer shall offer certificate holders an individual medicare supplement policy
ll neither cancel nor nonrenew a medicare supplement policy or certificate for any reason other than nonpayment of premium or material misrepresentation. (ii) If a group medicare supplement insurance policy is terminated by the group policyholder and not replaced as provided in paragraph (G)(1)(e)(iv) of this rule, the issuer shall offer certificate holders an individual medicare supplement policy. The issuer shall offer the certificate holder at least the following choices: (a) An individual medicare supplement policy currently offered by the issuer having comparable benefits to those contained in the terminated group medicare supplement policy; and (b) An individual medicare supplement policy which provides only such benefits as are required to meet the minimum standards as defined in paragraph (I)(2) of this rule. (iii) If membership in a group is terminated, the issuer shall: (a) Offer the certificate holder the conversion opportunities described in paragraph (G)(1)(e)(ii) of this rule; or (b) At the option of the group policyholder, offer the certificate holder continuation of coverage under the group policy. (iv) 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, such coverage to be effective the date the preceding policy terminates. Coverage under the new group policy shall not result in any exclusion for preexisting conditions that would have been covered under the group policy being replaced. (f) Termination of a medicare supplement policy or certificate shall be without prejudice to any continuous loss which commenced while the policy was in force, but the extension of benefits beyond the period during which the policy was in force may be predicated upon the continuous total disability of the insured, limited to the duration of the policy benefit period, if any, or to payment of the maximum benefits
of a medicare supplement policy or certificate shall be without prejudice to any continuous loss which commenced while the policy was in force, but the extension of benefits beyond the period during which the policy was in force may be predicated upon the continuous total disability of the insured, limited to the duration of the policy benefit period, if any, or to payment of the maximum benefits. Receipt of medicare "Part D" benefits will not be considered in determining a continuous loss. (g) 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 paragraph (G)(1) of this rule. (2) Minimum benefit standards. (a) Coverage of "Part A" medicare-eligible expenses for hospitalization to the extent not covered by medicare from the sixty-first day through the ninetieth day in any medicare benefit period. (b) Coverage for either all or none of the medicare "Part A" inpatient hospital deductible amount. (c) Coverage of "Part A" medicare-eligible expenses incurred as daily hospital charges during use of medicare's lifetime hospital inpatient reserve days. (d) Upon exhaustion of all medicare hospital inpatient coverage including the lifetime reserve days, coverage of at least ninety per cent of all medicare "Part A" eligible expenses for hospitalization not covered by medicare subject to a lifetime maximum benefit of an additional three hundred sixty-five days
daily hospital charges during use of medicare's lifetime hospital inpatient reserve days. (d) Upon exhaustion of all medicare hospital inpatient coverage including the lifetime reserve days, coverage of at least ninety per cent of all medicare "Part A" eligible expenses for hospitalization not covered by medicare subject to a lifetime maximum benefit of an additional three hundred sixty-five days. (e) Coverage under medicare "Part A" for the reasonable cost of the first three pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulations) unless replaced in accordance with federal regulations or already paid for under "Part B." (f) 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 a maximum calendar year out-of-pocket amount equal to the medicare "Part B" deductible [one hundred forty-seven dollars]. (g) Effective January 1, 1990, coverage under medicare "Part B" for the reasonable cost of the first three pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulations), unless replaced in accordance with federal regulations or already paid for under "Part A", subject to the medicare deductible amount. (H) Benefit standards for 1990 standardized medicare supplement benefit plan policies or certificates issued or delivered on or after May 1, 1992 and with an effective date for coverage prior to June 1, 2010. The following standards are applicable to all medicare supplement policies or certificates delivered or issued for delivery in this state on or after May 1, 1992 and with an effective date for 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
ds are applicable to all medicare supplement policies or certificates delivered or issued for delivery in this state on or after May 1, 1992 and with an effective date for 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. (1) General standards. The following standards apply to medicare supplement policies and certificates and are in addition to all other requirements of this rule. (a) A medicare supplement policy or certificate shall not exclude or limit benefits for losses incurred more than six 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 months before the effective date of coverage. (b) A medicare supplement policy or certificate shall not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents. (c) 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, in accordance with paragraph (R)(3)(b) of this rule. (d) 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. (e) Each medicare supplement policy shall be guaranteed renewable
modified to correspond with such changes, in accordance with paragraph (R)(3)(b) of this rule. (d) 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. (e) Each medicare supplement policy shall be guaranteed renewable. (i) The issuer shall not cancel or nonrenew the policy solely on the ground of health status of the individual; and (ii) The issuer shall not cancel or nonrenew the policy for any reason other than nonpayment of premium or material misrepresentation. (iii) If the medicare supplement policy is terminated by the group policyholder and is not replaced as provided under paragraph (H)(1)(e)(v) of this rule, the issuer shall offer each certificate holder an individual medicare supplement policy which (at the option of the certificate holder) (a) Provides for continuation of the benefits contained in the group policy; or (b) Provides for benefits that otherwise meet the requirements of this subsection. (iv) If an individual is a certificate holder in a group medicare supplement policy and the individual terminates membership in the group, the issuer shall: (a) Offer the certificate holder the conversion opportunity described in paragraph (H)(1)(e)(iii) of this rule; or (b) At the option of the group policyholder, offer the certificate holder continuation of coverage under the group policy. (v) If a group medicare supplement policy is replaced by another group medicare supplement policy purchased by the same policyholder, the issuer of the replacement policy shall offer coverage to all persons covered under the old group policy on its date of termination. Coverage under the new policy shall not result in any exclusion for preexisting conditions that would have been covered under the group policy being replaced
plement policy is replaced by another group medicare supplement policy purchased by the same policyholder, the issuer of the replacement policy shall offer coverage to all persons covered under the old group policy on its date of termination. Coverage under the new policy shall not result in any exclusion for preexisting conditions that would have been covered under the group policy being replaced. (vi) 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 paragraph (H)(1) of this rule. (f) 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. (g) (i) 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 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 days after the date the individual becomes entitled to assistance
lder for the period (not to exceed twenty-four 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 days after the date the individual becomes entitled to assistance. (ii) If suspension occurs and if the policyholder or certificate holder loses entitlement to such medical assistance, the 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 such entitlement within ninety days after the date of loss and pays the premium attributable to the period. (iii) Each medicare supplement policy shall provide that benefits and premiums under the policy shall be suspended (for any period that may be provided by federal regulation) at the request of the policyholder if the policyholder is entitled to benefits under section 226(b) of the "Social Security Act" and is covered under a group health plan (as defined in section 1862 (b)(1)(A)(v) of the "Social Security Act"). If suspension occurs and if the policyholder or certificateholder 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 the coverage within ninety days after the date of loss. (iv) Reinstitution of such coverages described in paragraphs (H)(1)(g)(ii) and (H)(1)(g)(iii) of this rule: (a) Shall not provide for any waiting period with respect to treatment of preexisting conditions; (b) Shall provide for resumption of coverage that is substantially equivalent to coverage in effect before the date of such suspension
of the coverage within ninety days after the date of loss. (iv) Reinstitution of such coverages described in paragraphs (H)(1)(g)(ii) and (H)(1)(g)(iii) of this rule: (a) Shall not provide for any waiting period with respect to treatment of preexisting conditions; (b) 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 (c) 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. (h) If an issuer makes a written offer to the medicare supplement policyholders or certificate holders of one or more of its plans, to exchange during a specified period from his or her 1990 standardized plan (as described in paragraph (J) of this rule) to a 2010 standardized plan (as described in paragraph (K) of this rule), the offer and subsequent exchange shall comply with the following requirements: (i) An issuer need not provide justification to the superintendent if the insured replaces a 1990 standardized policy or certificate with an issue age rated 2010 standardized policy or certificate at the insured's original issue age and duration. If an insured's policy or certificate to be replaced is priced on an issue age rate schedule at the time of such offer, the rate charged to the insured for the new exchanged policy shall recognize the policy reserve buildup, due to the prefunding inherent in the use of an issue age rate basis, for the benefit of the insured
ed policy or certificate at the insured's original issue age and duration. If an insured's policy or certificate to be replaced is priced on an issue age rate schedule at the time of such offer, the rate charged to the insured for the new exchanged policy shall recognize the policy reserve buildup, due to the prefunding inherent in the use of an issue age rate basis, for the benefit of the insured. The method proposed to be used by an issuer must be filed with the superintendent in accordance with paragraph (R) of this rule. (ii) The rating class of the new policy or certificate shall be the class closest to the insured's class of the replaced coverage. (iii) An issuer may not apply new pre-existing condition limitations or a new incontestability period to the new policy for those benefits contained in the exchanged 1990 standardized policy or certificate of the insured, but may apply pre-existing condition limitations of no more than six months to any added benefits contained in the new 2010 standardized policy or certificate not contained in the exchanged policy. (iv) The new policy or certificate shall be offered to all policyholders or certificate holders within a given plan, except where the offer or issue would be in violation of state or federal law. (2) Standards for basic ("core") benefits common to benefit plans "A" - "J" Every issuer shall make available to each prospective insured a policy or certificate including only the following basic "core" package of benefits. 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
2) Standards for basic ("core") benefits common to benefit plans "A" - "J" Every issuer shall make available to each prospective insured a policy or certificate including only the following basic "core" package of benefits. 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. (a) Coverage of "Part A" medicare-eligible expenses for hospitalization to the extent not covered by medicare from the sixty-first day through the ninetieth day in any medicare benefit period; (b) 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; (c) Upon exhaustion of the medicare hospital inpatient coverage, including the lifetime reserve days, coverage of one hundred per cent of the medicare "Part A" eligible expenses for hospitalization paid at the applicable prospective payment system ("PPS") rate, or other appropriate medicare standard of payment, subject to a lifetime maximum benefit of an additional three hundred sixty-five days. The provider shall accept the issuer's payment as payment in full and may not bill the insured for any balance; (d) Coverage under medicare "Parts A" and "B" for the reasonable cost of the first three pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulations) unless replaced in accordance with federal regulations; (e) 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. (3) Standards for additional benefits. The following additional benefits shall be included in medicare supplement benefit plans "B" through "J" only as provided by paragraph (J) of this rule
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. (3) Standards for additional benefits. The following additional benefits shall be included in medicare supplement benefit plans "B" through "J" only as provided by paragraph (J) of this rule. (a) Medicare "Part A" deductible: coverage for all of the medicare "Part A" inpatient hospital deductible amount per benefit period. (b) Skilled nursing facility care: coverage for the actual billed charges up to the coinsurance amount from the twenty-first day through the one hundredth day in a medicare benefit period for post-hospital skilled nursing facility care eligible under medicare "Part A"; (c) Medicare "Part B" deductible: coverage for all of the medicare "Part B" deductible amount per calendar year regardless of hospital confinement. (d) Eighty per cent of the medicare "Part B" excess charges: coverage for eighty per cent 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. (e) One hundred per cent 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. (f) Basic outpatient prescription drug benefit: coverage for fifty per cent of outpatient prescription drug charges, after a two hundred fifty dollar calendar year deductible, to a maximum of one thousand two hundred fifty dollars 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
for fifty per cent of outpatient prescription drug charges, after a two hundred fifty dollar calendar year deductible, to a maximum of one thousand two hundred fifty dollars 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. (g) Extended outpatient prescription drug benefit: coverage for fifty per cent of outpatient prescription drug charges, after a two hundred fifty dollar calendar year deductible to a maximum of three thousand dollars 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. (h) Medically necessary emergency care in a foreign country: coverage to the extent not covered by medicare for eighty per cent 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 consecutive days of each trip outside the "United States", subject to a calendar year deductible of two hundred fifty dollars, and a lifetime maximum benefit of fifty thousand dollars. For purposes of this benefit, "emergency care" shall mean care needed immediately because of an injury or an illness of sudden and unexpected onset
in the "United States" and which care began during the first sixty consecutive days of each trip outside the "United States", subject to a calendar year deductible of two hundred fifty dollars, and a lifetime maximum benefit of fifty thousand dollars. For purposes of this benefit, "emergency care" shall mean care needed immediately because of an injury or an illness of sudden and unexpected onset. (i) Preventive medical care benefit: coverage for the following preventive health services not covered by medicare: (i) An annual clinical preventive medical history and physical examination that may include tests and services from paragraph (H)(3)(i)(ii) of this rule and patient education to address preventive health care measures: (ii) Preventive screening tests or preventive services, the selection and frequency of which is determined to be medically appropriate by the attending physician. Reimbursement shall be for the actual charge up to one hundred per cent 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 annually under this benefit. This benefit shall not include payment for any procedure covered by medicare. (j) 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. (i) For purposes of this benefit, the following definitions shall apply: (a) "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. (b) "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
, dressing, personal hygiene, transferring, eating, ambulating, assistance with drugs that are normally self-administered, and changing bandages or other dressings. (b) "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. (c) "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. (d) "At-home recovery visit" means the period of a visit required to provide at home recovery care, without limit on the duration of the visit, except each consecutive four hours in a twenty-four hour period of services provided by a care provider is one visit. (ii) Coverage requirements and limitations (a) At-home recovery services provided must be primarily services which assist in activities of daily living. (b) 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. (c) 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 of forty dollars per visit. (iii) One thousand six hundred dollars per calendar year. (iv) Seven 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 paragraph (H)(3)(j) of this rule
sits under a medicare approved home care plan of treatment. (ii) The actual charges for each visit up to a maximum reimbursement of forty dollars per visit. (iii) One thousand six hundred dollars per calendar year. (iv) Seven 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 paragraph (H)(3)(j) of this rule. (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 weeks after the service date of the last medicare approved home health care visit. (iii) Coverage is excluded for: (a) Home care visits paid for by medicare or other government programs; and (b) Care provided by family members, unpaid volunteers or providers who are not care providers. (4) Standards for plans "K" and "L" (a) Standardized medicare supplement benefit plan "K" shall consist of the following: (i) Coverage of one hundred per cent of the "Part A" hospital coinsurance amount for each day used from the sixty-first through the ninetieth day in any medicare benefit period; (ii) Coverage of one hundred per cent of the "Part A" hospital coinsurance amount for each medicare lifetime inpatient reserve day used from the ninety-first through the one hundred fiftieth day in any medicare benefit period; (iii) Upon exhaustion of the medicare hospital inpatient coverage, including the lifetime reserve days, coverage of one hundred per cent of the medicare "Part A" eligible expenses for hospitalization paid at the applicable prospective payment system ("PPS") rate, or other appropriate medicare standard of payment, subject to a lifetime maximum benefit of an additional three hundred sixty-five days
(iii) Upon exhaustion of the medicare hospital inpatient coverage, including the lifetime reserve days, coverage of one hundred per cent of the medicare "Part A" eligible expenses for hospitalization paid at the applicable prospective payment system ("PPS") rate, or other appropriate medicare standard of payment, subject to a lifetime maximum benefit of an additional three hundred sixty-five days. The provider shall accept the issuer's payment as payment in full and may not bill the insured for any balance; (iv) Medicare "Plan A" deductible: coverage for fifty per cent of the medicare "Part A" inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in paragraph (H)(4)(a)(x) of this rule; (v) Skilled nursing facility care coverage for fifty per cent of the coinsurance amount for each day used from the twenty-first day through the one hundredth 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 paragraph (H)(4)(a)(x) of this rule; (vi) Hospice care coverage for fifty per cent of cost sharing for all "Part A" medicare-eligible expenses and respite care until the out-of-pocket limitation is met as described in paragraph (H)(4)(a)(x) of this rule; (vii) Coverage for fifty per cent under medicare "Parts A" or "B", of the reasonable cost of the first three 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 paragraph (H)(4)(a)(x) of this rule; (viii) Except for coverage provided in paragraph (H)(4)(a)(ix) of this rule, coverage for fifty per cent 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 paragraph (H)(4)(a)(x) of this rule: (ix) Coverage of one hundred
t as described in paragraph (H)(4)(a)(x) of this rule; (viii) Except for coverage provided in paragraph (H)(4)(a)(ix) of this rule, coverage for fifty per cent 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 paragraph (H)(4)(a)(x) of this rule: (ix) Coverage of one hundred per cent of the cost sharing for medicare "Part B" preventive services after the policyholder pays the "Part B" deductible; and (x) Coverage of one hundred per cent of all cost sharing under medicare "Parts A" and "B" for the balance of the calendar year after the individual has reached the out-of-pocket limitation on annual expenditures under medicare "Parts A" and "B" of four thousand dollars in 2006, indexed each year by the appropriate inflation adjustment specified by the secretary of the "United States" department of health and human services. (b) Standardized medicare supplement benefit plan "L" shall consist of the following: (i) The benefits described in paragraphs (H)(4)(a)(i), (H)(4)(a)(ii), (H)(4)(a)(iii), and (H)(4)(a)(ix) of this rule; (ii) The benefit described in paragraphs (H)(4)(a)(iv), (H)(4)(a)(v), (H)(4)(a)(vi), (H)(4)(a)(vii), and (H)(4)(a)(viii) of this rule, but substituting seventy-five per cent for fifty per cent; and (iii) The benefit described in paragraph (H)(4)(a)(x) of this rule, but substituting two thousand dollars for four thousand dollars. (I) Benefit standards for 2010 standardized medicare supplement benefit plan policies or certificates issued or delivered with an effective date for 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 for coverage on or after June 1, 2010
thousand dollars. (I) Benefit standards for 2010 standardized medicare supplement benefit plan policies or certificates issued or delivered with an effective date for 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 for coverage on or after June 1, 2010. No policy or certificate may be advertised, solicited, delivered or issued for delivery in this state as a medicare supplement policy or certificate unless it complies with these benefit standards. No issuer may offer any 1990 standardized medicare supplement benefit plan for sale on or after the June 1, 2010 effective date of these 2010 standardized medicare supplement benefit plan standards in this state. Benefit standards applicable to medicare supplement policies and certificates issued with an effective date for coverage prior to June 1, 2010 remain subject to the requirements of paragraph (H) of this rule. (1) General standards. The following standards apply to medicare supplement policies and certificates and are in addition to all other requirements of this rule. (a) A medicare supplement policy or certificate shall not exclude or limit benefits for losses incurred more than six 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 or received from a physician within six months before the effective date of coverage. (b) A medicare supplement policy or certificate shall not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents
ertificate may not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended or received from a physician within six months before the effective date of coverage. (b) A medicare supplement policy or certificate shall not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents. (c) 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. (d) 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. (e) Each medicare supplement policy shall be guaranteed renewable. (i) The issuer shall not cancel or nonrenew the policy solely on the ground of health status of the individual. (ii) The issuer shall not cancel or nonrenew the policy for any reason other than nonpayment of premium or material misrepresentation. (iii) If the medicare supplement policy is terminated by the group policyholder and is not replaced as provided under paragraph (I)(1)(e)(5) of this rule, the issuer shall offer certificate holders an individual medicare supplement policy which (at the option of the certificate holder): (a) Provides for the continuation of the benefits contained in the group policy; or (b) Provides for benefits that otherwise meet the requirements of paragraph (I) of this rule
up policyholder and is not replaced as provided under paragraph (I)(1)(e)(5) of this rule, the issuer shall offer certificate holders an individual medicare supplement policy which (at the option of the certificate holder): (a) Provides for the continuation of the benefits contained in the group policy; or (b) Provides for benefits that otherwise meet the requirements of paragraph (I) of this rule. (iv) If an individual is a certificate holder in a group medicare supplement policy and the individual terminates membership in the group, the issuer shall: (a) Offer the certificate holder the conversion opportunity described in paragraph (I)(1)(e)(3) of this rule; or (b) At the option of the group policyholder, offer the certificate holder continuation coverage under the group policy. (v) 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) 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
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. (g) (i) 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 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 days after the date the individual becomes entitled to assistance. (ii) If suspension occurs and if the policyholder or certificate holder loses entitlement to medical assistance, the policy or certificate shall be automatically reinstituted (effective as of the date of termination of entitlement) as of the termination of entitlement if the policyholder or certificate holder provides notice of loss of entitlement within ninety days after the date of loss and pays the premium attributable to the period, effective as of the date of termination of entitlement
dical assistance, the policy or certificate shall be automatically reinstituted (effective as of the date of termination of entitlement) as of the termination of entitlement if the policyholder or certificate holder provides notice of loss of entitlement within ninety days after the date of loss and pays the premium attributable to the period, effective as of the date of termination of entitlement. (iii) Each medicare supplement policy shall provide that benefits and premiums under the policy shall be suspended (for any period that may be provided by federal regulation) at the request of the policyholder if the policyholder is entitled to benefits under section 226(b) of the "Social Security Act" and is covered under a group health plan as defined in section 1862 (b)(1)(A)(v) of the "Social Security Act." If suspension occurs and if the policyholder or certificate holder loses coverage under the group health plan, the policy shall be automatically reinstituted (effective as of the date of loss of coverage) if the policyholder provides notice of loss of coverage within ninety days after the date of the loss. (iv) Reinstitution of coverages as described in paragraphs (I)(2) and (I)(3) of this rule: (a) Shall not provide for any waiting period with respect to treatment of preexisting conditions; (b) Shall provide for resumption of coverage that is substantially equivalent to coverage in effect before the date of suspension; and (c) 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. (2) Standards for basic (core) benefits common to medicare supplement insurance benefit plans "A," "B," "C," "D," "F," "F With High Deductible," "G," "M," and "N"
lassification 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. (2) Standards for basic (core) benefits common to medicare supplement insurance benefit plans "A," "B," "C," "D," "F," "F With High Deductible," "G," "M," and "N". Every issuer of medicare supplement insurance benefit plans shall make available a policy or certificate including only the following basic "core" package of benefits to each prospective insured. An issuer may make available to prospective insureds any of the other medicare supplement insurance benefit plans in addition to the basic core package, but not in lieu of it. (a) Coverage of "Part A" medicare-eligible expenses for hospitalization to the extent not covered by medicare from the sixty-first day through the ninetieth day in any medicare benefit period; (b) 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; (c) Upon exhaustion of the medicare hospital inpatient coverage, including the lifetime reserve days, coverage of one hundred per cent of the medicare "Part A" eligible expenses for hospitalization paid at the applicable prospective payment system ("PPS") rate, or other appropriate medicare standard of payment, subject to a lifetime maximum benefit of an additional three hundred sixty-five days
d; (c) Upon exhaustion of the medicare hospital inpatient coverage, including the lifetime reserve days, coverage of one hundred per cent of the medicare "Part A" eligible expenses for hospitalization paid at the applicable prospective payment system ("PPS") rate, or other appropriate medicare standard of payment, subject to a lifetime maximum benefit of an additional three hundred sixty-five days. The provider shall accept the issuer's payment as payment in full and may not bill the insured for any balance; (d) Coverage under medicare "Parts A" and "B" for the reasonable cost of the first three pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulations) unless replaced in accordance with federal regulations; (e) 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; (f) Hospice care: coverage of cost sharing for all "Part A" medicare eligible hospice care and respite care expenses. (3) Standards for additional benefits. The following additional benefits shall be included in medicare supplement benefit plans "B," "C," "D," "F," "F With High Deductible," "G," "M," and "N" as provided by paragraph (K) of this rule. (a) Medicare "Part A" deductible: coverage for one hundred per cent of the medicare "Part A" inpatient hospital deductible amount per benefit period. (b) Medicare "Part A" deductible: coverage for fifty per cent of the medicare "Part A" inpatient hospital deductible amount per benefit period
"B," "C," "D," "F," "F With High Deductible," "G," "M," and "N" as provided by paragraph (K) of this rule. (a) Medicare "Part A" deductible: coverage for one hundred per cent of the medicare "Part A" inpatient hospital deductible amount per benefit period. (b) Medicare "Part A" deductible: coverage for fifty per cent of the medicare "Part A" inpatient hospital deductible amount per benefit period. (c) Skilled nursing facility care: coverage for the actual billed charges up to the coinsurance amount from the twenty-first day through the one hundredth day in a medicare benefit period for post-hospital skilled nursing facility care eligible under medicare "Part A." (d) Medicare "Part B" deductible: coverage for one hundred per cent of the medicare "Part B" deductible amount per calendar year regardless of hospital confinement. (e) One hundred per cent 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. (f) Medically necessary emergency care in a foreign country: coverage to the extent not covered by medicare for eighty per cent 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 consecutive days of each trip outside the "United States," subject to a calendar year deductible of two hundred fifty dollars, and a lifetime maximum benefit of fifty thousand dollars. For purposes of this benefit, "emergency care" shall mean care needed immediately because of an injury or an illness of sudden and unexpected onset
in the "United States" and which care began during the first sixty consecutive days of each trip outside the "United States," subject to a calendar year deductible of two hundred fifty dollars, and a lifetime maximum benefit of fifty thousand dollars. For purposes of this benefit, "emergency care" shall mean care needed immediately because of an injury or an illness of sudden and unexpected onset. (J) Standard medicare supplement benefit plans for 1990 standardized medicare supplement benefit plan policies or certificates issued for delivery on or after May 1, 1992 and with an effective date for coverage prior to June 1, 2010. (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 paragraph (H)(2) of this rule. (2) No groups, packages or combinations of medicare supplement benefits other than those listed in paragraph (J) of this rule shall be offered for sale in this state, except as may be permitted in paragraphs (J) (7) and (M) of this rule. (3) Benefit plans shall be uniform in structure, language, designation and format to the standard benefit plans "A" through "L" listed in paragraph (J)(5) of this rule and conform to the definitions in paragraph (D) of this rule. Each benefit shall be structured in accordance with the format provided in paragraphs (H)(2) and (H)(3), or (H)(4) of this rule and list the benefits in the order shown in paragraph (J)(5) of this rule. For purposes of this paragraph, "structure, language, and format" means style, arrangement and overall content of a benefit. (4) An issuer may use, in addition to the benefit plan designations required in paragraph (J)(3) of this rule, other designations to the extent permitted by law. (5) Make-up of benefit plans: (a) Standardized medicare supplement benefit plan "A" shall be limited to the basic ("core") benefits common to all benefit plans, as defined in paragraph (H)(2) of this rule
and overall content of a benefit. (4) An issuer may use, in addition to the benefit plan designations required in paragraph (J)(3) of this rule, other designations to the extent permitted by law. (5) Make-up of benefit plans: (a) Standardized medicare supplement benefit plan "A" shall be limited to the basic ("core") benefits common to all benefit plans, as defined in paragraph (H)(2) of this rule. (b) Standardized medicare supplement benefit plan "B" shall include only the following: the core benefit as defined in paragraph (H)(2) of this rule, plus the medicare "Part A" deductible as defined in paragraph (H)(3)(a) of this rule. (c) Standardized medicare supplement benefit plan "C" shall include only the following: the core benefit as defined in paragraph (H)(2) 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 paragraphs (H)(3)(a), (H)(3)(b), (H)(3)(c), and (H)(3)(h) of this rule, respectively. (d) Standardized medicare supplement benefit plan "D" shall include only the following: the core benefit as defined in paragraph (H)(2) 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 paragraphs (H)(3)(a), (H)(3)(b), (H)(3)(h), and (H)(3)(j) of this rule, respectively. (e) Standardized medicare supplement benefit [regular] plan "E" shall include only the following: the core benefit as defined in paragraph (H)(2) 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 paragraphs (H)(3)(a), (H)(3)(b), (H)(3)(h), and (H)(3)(i) of this rule, respectively
ized medicare supplement benefit [regular] plan "E" shall include only the following: the core benefit as defined in paragraph (H)(2) 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 paragraphs (H)(3)(a), (H)(3)(b), (H)(3)(h), and (H)(3)(i) of this rule, respectively. (f) Standardized medicare supplement benefit plan "F" shall include only the following: the core benefit as defined in paragraph (H)(2) of this rule, plus the medicare "Part A" deductible, the skilled nursing facility care, the "Part B" deductible, one hundred per cent of the medicare "Part B" excess charges, and medically necessary emergency care in a foreign country as defined in paragraphs (H)(3)(a), (H)(3)(b), (H)(3)(c), (H)(3)(e), and (H)(3)(h) of this rule, respectively. (g) Standardized medicare supplement benefit high deductible plan "F" shall include only the following: one hundred per cent of covered expenses following the payment of the annual high deductible plan "F" deductible. The covered expenses include the core benefit as defined in paragraph (H)(2) of this rule, plus the medicare "Part A" deductible, skilled nursing facility care, the medicare "Part B" deductible, one hundred per cent of the medicare "Part B" excess charges, and medically necessary emergency care in a foreign country as defined in paragraphs (H)(3)(a), (H)(3)(b), (H)(3)(c), (H)(3)(e) and (H)(3)(h) of this rule, 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 fifteen hundred dollars for 1998 and 1999, and shall be based on the calendar year
rule, 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 fifteen hundred dollars for 1998 and 1999, and shall be based on the calendar year. It shall be adjusted annually thereafter by the secretary to reflect the change in the consumer price index for all urban consumers for the twelve-month period ending with August of the preceding year, and rounded to the nearest multiple of ten dollars. (h) Standardized medicare supplement benefit plan "G" shall include only the following: the core benefit as defined in paragraph (H)(2) of this rule, plus the medicare "Part A" deductible, skilled nursing facility care, eighty per cent of the medicare "Part B" excess charges, medically necessary emergency care in a foreign country, and the at-home recovery benefit as defined in paragraphs (H)(3)(a), (H)(3)(b), (H)(3)(d), (H)(3)(h), and (H)(3)(j) of this rule, respectively. (i) Standardized medicare supplement benefit plan "H" shall consist of only the following: the core benefit as defined in paragraph (H)(2) 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 paragraphs (H)(3)(a), (H)(3)(b), (H)(3)(f), and (H)(3)(h) of this rule, respectively. The outpatient prescription drug benefit shall not be included in a medicare supplement policy sold after December 31, 2005
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 paragraphs (H)(3)(a), (H)(3)(b), (H)(3)(f), and (H)(3)(h) of this rule, respectively. The outpatient prescription drug benefit shall not be included in a medicare supplement policy sold after December 31, 2005. (j) Standardized medicare supplement benefit plan "I" shall consist of only the following: the core benefit as defined in paragraph (H)(2) of this rule, plus the medicare "Part A" deductible, skilled nursing facility care, one hundred per cent 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 paragraphs (H)(3)(a), (H)(3)(b), (H)(3)(e), (H)(3)(f), (H)(3)(h), and (H)(3)(j) of this rule, respectively. The outpatient prescription drug benefit shall not be included in a medicare supplement policy sold after December 31, 2005. (k) Standardized medicare supplement benefit plan "J" shall consist of only the following: the core benefit as defined in paragraph (H)(2) of this rule, plus the medicare "Part A" deductible, skilled nursing facility care, medicare "Part B" deductible, one hundred per cent 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 paragraphs (H)(3)(a), (H)(3)(b), (H)(3)(c), (H)(3)(e), (H)(3)(g), (H)(3)(h), (H)(3)(i), and (H)(3)(j) of this rule, respectively. The outpatient prescription drug benefit shall not be included in a medicare supplement policy sold after December 31, 2005. (l) Standardized medicare supplement benefit high deductible plan "J" shall consist of only the following: one hundred per cent of covered expenses following the payment of the annual high deductible plan "J" deductible
), (H)(3)(i), and (H)(3)(j) of this rule, respectively. The outpatient prescription drug benefit shall not be included in a medicare supplement policy sold after December 31, 2005. (l) Standardized medicare supplement benefit high deductible plan "J" shall consist of only the following: one hundred per cent of covered expenses following the payment of the annual high deductible plan "J" deductible. The covered expenses include the core benefit as defined in paragraph (H)(2) of this rule, plus the medicare "Part A" deductible, skilled nursing facility care, medicare "Part B" deductible, one hundred per cent 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 paragraphs (H)(3)(a), (H)(3)(b), (H)(3)(c), (H)(3)(e), (H)(3)(g), (H)(3)(h), (H)(3)(i), and (H)(3)(j) of this rule, 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 fifteen hundred dollars for 1998 and 1999, and shall be based on a calendar year. It shall be adjusted annually thereafter by the secretary to reflect the change in the consumer price index for all urban consumers for the twelve-month period ending with August of the preceding year, and rounded to the nearest multiple of ten dollars. The outpatient prescription drug benefit shall not be included in a medicare supplement policy sold after December 31, 2005
ed 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 ten dollars. The outpatient prescription drug benefit shall not be included in a medicare supplement policy sold after December 31, 2005. (6) Make-up of two medicare supplement plans mandated by "The Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA)"; (a) Standardized medicare supplement benefit plan "K" shall consist of only those benefits described in paragraph (H)(4)(a) of this rule: (b) Standardized medicare supplement benefit plan "L" shall consist of only those benefits described in paragraph (H)(4)(b) of this rule. (7) 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. (K) Standard medicare supplement benefit plans for 2010 standardized medicare supplement benefit plan policies or certificates issued for delivery with an effective date for coverage on or after June 1, 2010. The following standards are applicable to all medicare supplement policies or certificates delivered or issued for delivery in this state with an effective date for coverage on or after June 1, 2010
ndard medicare supplement benefit plans for 2010 standardized medicare supplement benefit plan policies or certificates issued for delivery with an effective date for coverage on or after June 1, 2010. The following standards are applicable to all medicare supplement policies or certificates delivered or issued for delivery in this state with an effective date for coverage on or after June 1, 2010. No policy or certificate may be advertised, solicited, delivered or issued for delivery in this state as a medicare supplement policy or certificate unless it complies with these benefit plan standards. Benefit plan standards applicable to medicare supplement policies and certificates issued with an effective date for coverage before June 1, 2010 remain subject to the requirements of paragraph (J) of this rule. (1) An issuer shall make available to each prospective policyholder and certificate holder a policy form containing only the basic (core) benefits, as defined in paragraph (I)(2) of this rule. (2) If an issuer makes available any of the additional benefits described in paragraph (I)(3) of this rule, or offers standardized benefit plans "K" or "L" as described in paragraphs (K)(5)(h) and (K)(5)(i) of this rule, then the issuer shall make available to each prospective policyholder and certificate holder, in addition to a policy form or certificate form with only the basic (core) benefits as described in the first sentence of paragraph (K) of this rule, a policy form or certificate form containing either standardized benefit plan "C" as described in paragraph (K)(5)(c) of this rule or standardized benefit plan "F" as described in paragraph (K)(5)(e) of this rule. (3) No groups, packages or combinations of medicare supplement benefits other than those listed in this paragraph (K) of this rule shall be offered for sale in this state, except as may be provided in paragraphs (K)(7) and (M) of this rule
tandardized benefit plan "C" as described in paragraph (K)(5)(c) of this rule or standardized benefit plan "F" as described in paragraph (K)(5)(e) of this rule. (3) No groups, packages or combinations of medicare supplement benefits other than those listed in this paragraph (K) of this rule shall be offered for sale in this state, except as may be provided in paragraphs (K)(7) and (M) of this rule. (4) Benefit plans shall be uniform in structure, language, designation and format to the standard benefit plans listed in this paragraph and conform to the definitions in paragraph (D) of this rule. Each benefit shall be structured in accordance with the format provided in paragraphs (I)(2) and (I)(3) of this rule; or, in the case of plans "K" or "L," in paragraph (K)(6)(h) or (K)(6)(i) of this rule and list the benefits in the order shown. For purposes of this paragraph, "structure, language, and format" means style, arrangement and overall content of a benefit. (5) In addition to the benefit plan designations required in paragraph (K)(4) of this rule, an issuer may use other designations to the extent permitted by law. (6) Make-up of 2010 standardized benefit plans. (a) Standardized medicare supplement benefit plan "A" shall include only the following: the basic (core) benefits as defined in paragraph (I)(2) of this rule. (b) Standardized medicare supplement benefit plan "B" shall include only the following: the basic (core) benefit as defined in paragraph (I)(2) of this rule, plus one hundred per cent of the medicare "Part A" deductible as defined in paragraph (I)(3)(a) of this rule
supplement benefit plan "A" shall include only the following: the basic (core) benefits as defined in paragraph (I)(2) of this rule. (b) Standardized medicare supplement benefit plan "B" shall include only the following: the basic (core) benefit as defined in paragraph (I)(2) of this rule, plus one hundred per cent of the medicare "Part A" deductible as defined in paragraph (I)(3)(a) of this rule. (c) Standardized medicare supplement benefit plan "C" shall include only the following: the basic (core) benefit as defined in paragraph (I)(2) of this rule, plus one hundred per cent of the medicare "Part A" deductible, skilled nursing facility care, one hundred per cent of the medicare "Part B" deductible, and medically necessary emergency care in a foreign country as defined in paragraphs (I)(3)(a), (I)(3)(c), (I)(3)(d) and (I)(3)(f) of this rule, respectively. (d) Standardized medicare supplement benefit plan "D" shall include only the following: the basic (core) benefit (as defined in paragraph (I)(2) of this rule), plus one hundred per cent of the medicare "Part A" deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in paragraphs (I)(3)(a), (I)(3)(c) and (I)(3)(f) of this rule, respectively. (e) Standardized medicare supplement benefit [regular] plan "F" shall include only the following: the basic (core) benefit as defined in paragraph (I)(2) of this rule, plus one hundred per cent of the medicare "Part A" deductible, the skilled nursing facility care, one hundred per cent of the medicare "Part B" deductible, one hundred per cent of the medicare "Part B" excess charges, and medically necessary emergency care in a foreign country as defined in paragraphs (I)(3)(a), (I)(3)(c), (I)(3)(d), (I)(3)(e) and (I)(3)(f) of this rule, respectively
of this rule, plus one hundred per cent of the medicare "Part A" deductible, the skilled nursing facility care, one hundred per cent of the medicare "Part B" deductible, one hundred per cent of the medicare "Part B" excess charges, and medically necessary emergency care in a foreign country as defined in paragraphs (I)(3)(a), (I)(3)(c), (I)(3)(d), (I)(3)(e) and (I)(3)(f) of this rule, respectively. (f) Standardized medicare supplement plan "F With High Deductible" shall include only the following: one hundred per cent of covered expenses following the payment of the annual deductible set forth in paragraph (K)(6)(f)(ii) of this rule. (i) The basic (core) benefit as defined in paragraph (I)(2) of this rule, plus one hundred per cent of the medicare "Part A" deductible, skilled nursing facility care, one hundred per cent of the medicare "Part B" deductible, one hundred per cent of the medicare "Part B" excess charges, and medically necessary emergency care in a foreign country as defined in paragraphs (I)(3)(a), (I)(3)(c), (I)(3)(d), (I)(3)(e) and (I)(3)(f) of this rule, respectively. (ii) The annual deductible in plan "F With High Deductible" shall consist of out-of-pocket expenses, other than premiums, for services covered by [regular] plan "F," and shall be in addition to any other specific benefit deductibles. The basis for the deductible shall be one thousand five hundred dollars, and shall be adjusted annually from 1999 by the secretary of the "United States" department of health and human services to reflect the changes 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
ductibles. The basis for the deductible shall be one thousand five hundred dollars, and shall be adjusted annually from 1999 by the secretary of the "United States" department of health and human services to reflect the changes 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. (g) Standardized medicare supplement benefit plan "G" shall include only the following: the basic (core) benefit as defined in paragraph (I)(2) of this rule, plus one hundred per cent of the medicare "Part A" deductible, skilled nursing facility care, one hundred per cent of the medicare "Part B" excess charges, and medically necessary emergency care in a foreign country as defined in paragraphs (I)(3)(a), (I)(3)(c), (I)(3)(e) and (I)(3)(f) of this rule, respectively. Effective January 1, 2020, the standardized benefit plans described in paragraph (L)(1)(d) of the rule (redesignated plan G high deductible) may be offered to any individual who was eligible for medicare prior to January 1, 2020. (h) Standardized medicare supplement plan "K" is mandated by the "Medicare Prescription Drug, Improvement and Modernization Act of 2003," and shall include only the following: (i) "Part A" hospital coinsurance, sixty-first through ninetieth days: coverage of one hundred per cent of the "Part A" hospital coinsurance amount for each day used from the sixty-first through the ninetieth day in any medicare benefit period; (ii) "Part A" hospital coinsurance, ninety-first through one hundred fiftieth days: coverage of one hundred per cent of the "Part A" hospital coinsurance amount for each medicare lifetime inpatient reserve day used from the ninety-first through the one hundred fiftieth day in any medicare benefit period; (iii) "Part A" hospitalization after lifetime reserve days are exhausted: Upon exhaustion of the medicare hospital inpatient coverage, including the lifetime reserve days, coverage of one hundred per cent of the medi
e "Part A" hospital coinsurance amount for each medicare lifetime inpatient reserve day used from the ninety-first through the one hundred fiftieth day in any medicare benefit period; (iii) "Part A" hospitalization after lifetime reserve days are exhausted: Upon exhaustion of the medicare hospital inpatient coverage, including the lifetime reserve days, coverage of one hundred per cent of the medicare "Part A" eligible expenses for hospitalization paid at the applicable prospective payment system ("PPS") rate, or other appropriate medicare standard of payment, subject to a lifetime maximum benefit of an additional three hundred sixty-five days. The provider shall accept the issuer's payment as payment in full and may not bill the insured for any balance; (iv) Medicare "Part A" deductible: coverage for fifty per cent of the medicare "Part A" inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in paragraph (K)(6)(h)(x) of this rule. (v) Skilled nursing facility care: coverage for fifty per cent of the coinsurance amount for each day used from the twenty-first day through the one hundredth 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 paragraph (K)(6)(h)(x) of this rule. (vi) Hospice care: coverage for fifty per cent of cost sharing for all "Part A" medicare eligible expenses and respite care until the out-of-pocket limitation is met as described in paragraph (K)(6)(h)(x) of this rule. (vii) Blood: coverage for fifty per cent, under medicare "Part A" or "B," of the reasonable cost of the first three 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 paragraph (K)(6)(h)(x) of this rule
graph (K)(6)(h)(x) of this rule. (vii) Blood: coverage for fifty per cent, under medicare "Part A" or "B," of the reasonable cost of the first three 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 paragraph (K)(6)(h)(x) of this rule. (viii) "Part B" cost sharing: except for coverage provided in paragraph (K)(6)(h)(ix) of this rule, coverage for fifty per cent of the cost sharing otherwise applicable under medicare "Part B" after the policyholder pays the deductible until the out-of-pocket limitation is met as described in paragraph (K)(6)(h)(x) of this rule. (ix) "Part B" preventive services: coverage of one hundred per cent of the cost sharing for medicare "Part B" preventive services after the policyholder pays the "Part B" deductible; and (x) Cost sharing after out-of-pocket limits: coverage of one hundred per cent of all cost sharing under medicare "Parts A" and "B" for the balance of the calendar year after the individual has reached the out-of-pocket limitation on annual expenditures under medicare "Parts A" and "B" of four thousand dollars in 2006, indexed each year by the appropriate inflation adjustment specified by the secretary of the "United States" department of health and human services. (i) Standardized medicare supplement plan "L" is mandated by the "Medicare Prescription Drug, Improvement and Modernization Act of 2003," and shall include only the following: (i) The benefits described in paragraphs (K)(6)(h)(i), (K)(6)(h)(ii), (K)(6)(h)(iii) and (K)(6)(h)(ix) of this rule; (ii) The benefit described in paragraphs (K)(6)(h)(iv), (K)(6)(h)(v), (K)(6)(h)(vi), (K)(6)(h)(vii) and (K)(6)(h)(viii) of this rule, but substituting seventy-five per cent for fifty per cent; and (iii) The benefit described in paragraph (K)(6)(h)(x) of this rule, but substituting two thousand dollars for four thousand dollars
6)(h)(i), (K)(6)(h)(ii), (K)(6)(h)(iii) and (K)(6)(h)(ix) of this rule; (ii) The benefit described in paragraphs (K)(6)(h)(iv), (K)(6)(h)(v), (K)(6)(h)(vi), (K)(6)(h)(vii) and (K)(6)(h)(viii) of this rule, but substituting seventy-five per cent for fifty per cent; and (iii) The benefit described in paragraph (K)(6)(h)(x) of this rule, but substituting two thousand dollars for four thousand dollars. (j) Standardized medicare supplement plan "M" shall include only the following: the basic (core) benefit as defined in paragraph (I)(2) of this rule, plus fifty per cent of the medicare "Part A" deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in paragraphs (I)(3)(b), (I)(3)(c) and (I)(3)(f) of this rule, respectively. (k) Standardized medicare supplement plan "N" shall include only the following: the basic (core) benefit as defined in paragraph (I)(2) of this rule, plus one hundred per cent of the medicare "Part A" deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in paragraphs (I)(3)(a), (I)(3)(c) and (I)(3)(f) of this rule, respectively, with copayments in the following amounts: (i) The lesser of twenty dollars or the medicare "Part B" coinsurance or copayment for each covered health care provider office visit (including visits to medical specialists); and (ii) The lesser of fifty dollars 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. (7) 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
red is admitted to any hospital and the emergency visit is subsequently covered as a medicare "Part A" expense. (7) 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. Approval of new or innovative benefits must not adversely impact the goal of medicare supplement simplification. New or innovative benefits shall not include an outpatient prescription drug benefit. New or innovative benefits shall not be used to change or reduce benefits, including a change of any cost-sharing provision, in any standardized plan. (L) Standard medicare supplement benefit plans for year 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 are applicable to all medicare supplement policies or certificates delivered or issued for delivery in this state to individuals newly eligible for medicare on or after January 1, 2020. No policy or certificate that provides coverage of the medicare "Part B" deductible may be advertised, solicited, delivered or issued for delivery in this state as a medicare supplement policy or certificate to individuals newly eligible for medicare on or after January 1, 2020. All policies must comply with the following benefit standards. Benefit plan standards applicable to medicare supplement policies and certificates issued to individuals eligible for medicare before January 1, 2020, remain subject to the requirements of paragraph (K) of this rule. (1) Benefit requirements
t 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 paragraph (K) of this rule. (1) Benefit requirements. The standards and requirements of paragraph (K) of this rule 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: (a) Standardized medicare supplement benefit plan "C" is redesignated as plan "D" and shall provide the benefits contained in paragraph (K)(6)(c) of this rule but shall not provide coverage for one hundred per cent or any portion of the medicare "Part B" deductible. (b) Standardized medicare supplement benefit plan "F" is redesignated as plan "G" and shall provide the benefits contained in paragraph (K)(6)(e) of this rule but shall not provide coverage for one hundred per cent or any portion of the medicare "Part B" deductible. (c) 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. (d) Standardized medicare supplement benefit "Plan F With High Deductible" is redesignated as "Plan G With High Deductible" and shall provide the benefits contained in paragraph (K)(6)(f) of this rule but shall not provide coverage for one hundred per cent or any portion of the medicare "Part B" deductible; provided further that, the medicare "Part B" deductible paid by the beneficiary shall be considered an out-of-pocket expense in meeting the annual high deductible. (e) The reference to plan "C" or "F" contained in paragraph (K)(2) of this rule is deemed a reference to plan "D" or "G" for purposes of paragraph (L) of this rule
one hundred per cent or any portion of the medicare "Part B" deductible; provided further that, the medicare "Part B" deductible paid by the beneficiary shall be considered an out-of-pocket expense in meeting the annual high deductible. (e) The reference to plan "C" or "F" contained in paragraph (K)(2) of this rule is deemed a reference to plan "D" or "G" for purposes of paragraph (L) of this rule. (2) Applicability to certain individuals. Paragraph (L) of this rule, applies to only individuals that are newly eligible for medicare on or after January 1, 2020. (a) By reason of attaining age sixty-five on or after January 1, 2020; or (b) 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. (3) Guaranteed issue for eligible persons. For purposes of paragraph (O)(5) of this rule, in the case of any individual newly eligible for medicare on or after January 1, 2020, any reference to a medicare supplement policy "C" or "F" (including "F With High Deductible") shall be deemed to be a reference to medicare supplement policy "D" or "G" (including "G With High Deductible"), respectively, that meet the requirements of paragraph (L)(1) of this rule. (4) Offer of redesignated plans to individuals other than newly eligible. On or after January 1, 2020, the standardized benefit plans described in paragraph (L)(1)(d) of this rule, may be offered to any individual who was eligible for medicare prior to January 1, 2020, in addition to the standardized plans described in paragraph (K)(6) of this rule. (M) Medicare select policies and certificates, as defined in this paragraph. (1) (a) This paragraph shall apply to medicare select policies and certificates, as defined in this paragraph. (b) No policy or certificate may be advertised as a medicare select policy or certificate unless it meets the requirements of this paragraph
n to the standardized plans described in paragraph (K)(6) of this rule. (M) Medicare select policies and certificates, as defined in this paragraph. (1) (a) This paragraph shall apply to medicare select policies and certificates, as defined in this paragraph. (b) No policy or certificate may be advertised as a medicare select policy or certificate unless it meets the requirements of this paragraph. (2) For the purposes of this paragraph: (a) "Complaint" means any dissatisfaction expressed by an individual concerning a medicare select issuer or its network providers. (b) "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. (c) "Medicare select issuer" means an issuer offering, or seeking to offer, a medicare select policy or certificate. (d) "Medicare select policy" or "medicare select certificate" mean respectively a medicare supplement policy or certificate that contains restricted network provisions. (e) "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. (f) "Restricted network provision" means any provision which conditions the payment of benefits, in whole or in part, on the use of network providers. (g) "Service area" means the geographic area approved by the superintendent within which an issuer is authorized to offer a medicare select policy. (3) The superintendent may authorize an issuer to offer a medicare select policy or certificate, pursuant to this paragraph 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
rea approved by the superintendent within which an issuer is authorized to offer a medicare select policy. (3) The superintendent may authorize an issuer to offer a medicare select policy or certificate, pursuant to this paragraph 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. (4) A medicare select issuer shall not issue a medicare select policy or certificate in this state until its plan of operation has been approved by the superintendent. (5) 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: (a) Evidence that all covered services that are subject to restricted network provisions are available and accessible through network providers, including a demonstration that: (i) 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. (ii) The number of network providers in the service area is sufficient, with respect to current and expected policyholders, either: (a) To deliver adequately all services that are subject to a restricted network provision; or (b) To make appropriate referrals. (iii) There are written agreements with network providers describing specific responsibilities. (iv) Emergency care is available twenty-four hours per day and seven days per week
the service area is sufficient, with respect to current and expected policyholders, either: (a) To deliver adequately all services that are subject to a restricted network provision; or (b) To make appropriate referrals. (iii) There are written agreements with network providers describing specific responsibilities. (iv) Emergency care is available twenty-four hours per day and seven days per week. (v) 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. (b) A statement or map providing a clear description of the service area. (c) A description of the grievance procedure to be utilized. (d) A description of the quality assurance program, including: (i) The formal organizational structure; (ii) The written criteria for selection, retention and removal of network providers; and (iii) The procedures for evaluating quality of care provided by network providers, and the process to initiate corrective action when warranted. (e) A list and description, by specialty, of the network providers. (f) Copies of the written information proposed to be used by the issuer to comply with paragraph (M)(9) of this rule. (g) Any other information requested by the superintendent. (6) (a) 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 days unless specifically disapproved. (b) An updated list of network providers shall be filed with the superintendent at least quarterly
e 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 days unless specifically disapproved. (b) An updated list of network providers shall be filed with the superintendent at least quarterly. (7) A medicare select policy or certificate shall not restrict payment for covered services provided by non-network providers if: (a) The services are for symptoms requiring emergency care or are immediately required for an unforeseen illness, injury or a condition; and (b) It is not reasonable to obtain such services through a network provider. (8) A medicare select policy or certificate shall provide payment for full coverage under the policy for covered services that are not available through network providers. (9) A medicare select issuer shall make full and fair disclosure in writing of the provisions, restrictions, and limitations of the medicare select policy or certificate to each applicant. This disclosure shall include at least the following: (a) An outline of coverage as required by paragraph (T)(4)(c) of this rule, in the form prescribed in appendix C to this rule sufficient to permit the applicant to compare coverage and premiums of the medicare select policy or certificate with: (i) Other medicare supplement policies or certificates offered by the issuer; and (ii) Other medicare select policies or certificates. (b) A description (including address, phone number and hours of operation) of the network providers, including primary care physicians, specialty physicians, hospitals, and other providers. (c) A description of the restricted network provisions, including payments for coinsurance and deductibles when providers other than network providers are utilized
ther medicare select policies or certificates. (b) A description (including address, phone number and hours of operation) of the network providers, including primary care physicians, specialty physicians, hospitals, and other providers. (c) 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". (d) A description of coverage for emergency and urgently needed care and other out-of-service area coverage. (e) A description of limitations on referrals to restricted network providers and to other providers. (f) A description of the policyholder's right to purchase any other medicare supplement policy or certificate otherwise offered by the issuer. (g) A description of the medicare select issuer's quality assurance program and grievance procedure. (10) Prior to the sale of a medicare select policy or certificate, a medicare select issuer shall obtain from the applicant a signed and dated form stating that the applicant has received the information provided pursuant to paragraph (M)(9) of this rule and that the applicant understands the restrictions of the medicare select policy or certificate. (11) 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. (a) The grievance procedure shall be described in the policy and certificates and in the outline of coverage. (b) 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
ers. Such procedures shall be aimed at mutual agreement for settlement and may include arbitration procedures. (a) The grievance procedure shall be described in the policy and certificates and in the outline of coverage. (b) 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. (c) 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. (d) If a grievance is found to be valid, corrective action shall be taken promptly. (e) All concerned parties shall be notified about the results of a grievance. (f) The issuer shall report no later than each March thirty-first 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. (12) At the time of initial purchase, a medicare select issuer shall make available to each applicant for a medicare select policy or certificate the opportunity to purchase any medicare supplement policy or certificate otherwise offered by the issuer. (13) (a) 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 such policies or certificates available without requiring evidence of insurability after the medicare select policy or certificate has been in force for six months
he 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 such policies or certificates available without requiring evidence of insurability after the medicare select policy or certificate has been in force for six months. (b) For the purposes of paragraph (M)(13) of this rule, 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. (14) 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 paragraph should be discontinued due to either the failure of the medicare select program to be reauthorized under law or its substantial amendment. (a) 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. (b) For the purposes of paragraph (M)(14) of this rule, 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
provision. The issuer shall make such policies and certificates available without requiring evidence of insurability. (b) For the purposes of paragraph (M)(14) of this rule, 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. (15) 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. (N) Open enrollment (1) 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 a policy or certificate because of the health status (including tobacco or nicotine usage), claims experience, receipt of health care, or medical condition of an applicant in the case of an application for a policy or certificate that is submitted prior to or during the six month period beginning with the first day of the first month in which an individual is both sixty-five years of age or older and is enrolled for benefits under medicare "Part B." Each medicare supplement policy and certificate currently available from an issuer shall be made available to all applicants who qualify under paragraph (N)(1) of this rule without regard to age. (2) (a) If an applicant qualifies under paragraph (N)(1) of this rule and submits an application during the time period referenced in paragraph (N)(1) of this rule and, as of the date of application, has had a continuous period of creditable coverage of at least six months, the issuer shall not exclude benefits based on a preexisting condition
r paragraph (N)(1) of this rule without regard to age. (2) (a) If an applicant qualifies under paragraph (N)(1) of this rule and submits an application during the time period referenced in paragraph (N)(1) of this rule and, as of the date of application, has had a continuous period of creditable coverage of at least six months, the issuer shall not exclude benefits based on a preexisting condition. (b) If the applicant qualifies under paragraph (N)(1) of this rule and submits an application during the time period referenced in paragraph (N)(1) of this rule and, as of the date of application, has had a continuous period of creditable coverage that is less than six 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. The secretary shall specify the manner of the reduction under this paragraph. (3) Except as provided in paragraphs (N)(2), (O), and (Z) of this rule, paragraph (N)(1) of this rule shall not be construed as preventing the exclusion of benefits under a policy, during the first six months, based on a preexisting condition for which the policyholder or certificate holder received treatment or was otherwise diagnosed during the six months before the coverage became effective. (4) In connection with the solicitation or sale of a medicare supplement policy or certificate to persons who qualify under paragraph (N)(1) of this rule, no issuer shall: (a) Engage in any act or practice with the intent or effect of restricting the sale to or discouraging the purchase by persons eligible for open enrollment of any medicare supplement policy or certificate available in this state
(4) In connection with the solicitation or sale of a medicare supplement policy or certificate to persons who qualify under paragraph (N)(1) of this rule, no issuer shall: (a) Engage in any act or practice with the intent or effect of restricting the sale to or discouraging the purchase by persons eligible for open enrollment of any medicare supplement policy or certificate available in this state. Such acts or practices include but are not limited to the following: (i) Creating a disincentive for producers to sell medicare supplement policies or certificates during the open enrollment period through compensation arrangements that reduce or eliminate compensation for sales made to persons eligible for open enrollment; (ii) Applying waiting periods for coverage of pre-existing conditions as described in paragraph (N)(2) of this rule only to policies or certificates issued to persons eligible for open enrollment; (iii) Engaging in premium rating practices which result in premiums which are higher for persons eligible for open enrollment than premiums for persons not eligible for open enrollment; (iv) Failing to offer to persons eligible for open enrollment any medicare supplement policy or certificate which is available for purchase from the issuer i

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Source: Frix Law Library, https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_3901_8_08. Check the current official text before relying on it. Not legal advice.