Conn. Agencies Regs. § 38a-495a-5 - Benefit standards for policies or certificates issued or delivered on or after July 30, 1992 and with an effective date for coverage prior to June 2010
The following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this state on or after July 30, 1992 and with an effective date for coverage prior to June 2010. No policy or certificate may be advertised, solicited, delivered or issued for delivery in this state as a Medicare supplement policy or certificate unless it complies with these benefit standards.
(a)
General Standards. The
following standards apply to Medicare supplement policies and certificates and
are in addition to all other requirements of this regulation.
(1) A Medicare supplement policy or
certificate shall not exclude or limit benefits for losses incurred more than
six (6) months from the effective date of coverage because it involved a
preexisting condition. The policy or certificate may not define a preexisting
condition more restrictively than a condition for which medical advice was
given or treatment was recommended by or received from a physician within six
(6) months before the effective date of coverage.
(2) A Medicare supplement policy or
certificate shall not indemnify against losses resulting from sickness on a
different basis than losses resulting from accidents.
(3) A Medicare supplement policy or
certificate shall provide that benefits designed to cover cost sharing amounts
under Medicare will be changed automatically to coincide with any changes in
the applicable Medicare deductible, copayment or coinsurance amounts. Premiums
may be modified to correspond with such changes only with the prior approval of
the commissioner.
(4) No Medicare
supplement policy or certificate shall provide for termination of coverage of a
spouse solely because of the occurrence of an event specified for termination
of coverage of the insured, other than the nonpayment of premium.
(5) Each Medicare supplement policy shall be
guaranteed renewable and;
(A) The issuer shall
not cancel or nonrenew the policy solely on the ground of health status of the
individual; and
(B) The issuer
shall not cancel or nonrenew the policy for any reason other than nonpayment of
premium or material misrepresentation.
(C) If the Medicare supplement policy is
terminated by the group policyholder and is not replaced as provided under
subparagraph (E) of this subdivision, the issuer shall offer certificateholders
an individual Medicare supplement policy which (at the option of the
certificateholder):
(i) Provides for
continuation of the benefits contained in the group policy, or
(ii) Provides for such benefits as otherwise
meets the requirements of this subsection.
(D) If an individual is a certificateholder
in a group Medicare supplement policy and the individual terminates membership
in the group, the issuer shall:
(i) Offer the
certificateholder the conversion opportunity described in subparagraph (C) of
this subdivision, or
(ii) At the
option of the group policyholder, offer the certificateholder continuation of
coverage under the group policy.
(E) If a group Medicare supplement policy is
replaced by another group Medicare supplement policy purchased by the same
policyholder, the issuer of the replacement policy shall offer coverage to all
persons covered under the old group policy on its date of termination. Coverage
under the new policy shall not result in any exclusion for preexisting
conditions that would have been covered under the group policy being
replaced.
(6)
Termination of a Medicare supplement policy or certificate shall be without
prejudice to any continuous loss which commenced while the policy was in force,
but the extension of benefits beyond the period during which the policy was in
force may be conditioned upon the continuous total disability of the insured,
limited to the duration of the policy benefit period, if any, or payment of the
maximum benefits. Receipt of Medicare Part D benefits shall not be considered
in determining a continuous loss.
(7) If a Medicare supplement policy
eliminates an outpatient prescription drug benefit as a result of requirements
imposed by the Medicare Prescription Drug, Improvement, and Modernization Act
of 2003, the modified policy shall be deemed to satisfy the guaranteed renewal
requirements of this subsection.
(8)
(A) A
Medicare supplement policy or certificate shall provide that benefits and
premiums under the policy or certificate shall be suspended at the request of
the policyholder or certificateholder for the period (not to exceed twenty-four
(24) months) in which the policyholder or certificateholder 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 certificateholder notifies
the issuer of such policy or certificate within ninety (90) days after the date
the individual becomes entitled to such assistance.
(B) If such suspension occurs and if the
policyholder or certificateholder loses entitlement to such medical assistance,
such policy or certificate shall be automatically reinstituted (effective as of
the date of termination of such entitlement) as of the termination of such
entitlement if the policyholder or certificateholder provides notice of loss of
such entitlement within ninety (90) days after the date of such loss and pays
the premium attributable to the period, effective as of the date of termination
of such entitlement.
(C) Each
Medicare supplement policy or certificate shall provide that benefits and
premiums under the policy or certificate shall be suspended (for any period
that may be provided by federal regulation) at the request of the policyholder
or certificateholder if the policyholder or certificate holder 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 such suspension occurs, and if the policyholder or
certificateholder loses coverage under the group health plan, the policy or
certificate shall be automatically reinstituted (effective as of the date of
loss of such coverage) if the policyholder or certificateholder provides notice
of loss of coverage within 90 days after the date of such loss of
coverage.
(D) Reinstitution of
coverage as described in subparagraphs (B) and (C) of this subdivision:
(i) Shall not provide for any waiting period
with respect to treatment of preexisting conditions;
(ii) Shall provide for resumption of coverage
which is substantially equivalent to coverage in effect before the date of
suspension.If the suspended Medicare supplement policy provided coverage for
outpatient prescription drugs, reinstitution of the policy for Medicare Part D
enrollees shall be without coverage for outpatient prescription drugs and shall
otherwise provide substantially equivalent coverage to the coverage in effect
before the date of suspension; and
(iii) Shall provide for classification of
premiums on terms at least as favorable to the policyholder or
certificateholder as the premium classification terms that would have applied
to the policyholder or certificateholder had the coverage not been
suspended.
(9) If an issuer makes a written offer to the
Medicare supplement policyholders or certificateholders of one or more of its
plans, to exchange during a specified period his or her 1992 standardized
benefit plan as described in section
38a-495a-6
of the Regulations of Connecticut State Agencies, for a 2010 standardized
benefit plan as described in section
38a-495a-6
a of the Regulations of Connecticut State Agencies, the offer and subsequent
exchange shall comply with the following requirements:
(A) An issuer may not apply new pre-existing
limitations or a new incontestability period to the new policy for those
benefits contained in the exchanged 1992 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 benefit
plan not contained in the exchanged plan.
(B) The new policy or certificate shall be
offered to all policyholders or certificateholders within a given plan except
where the offer or issue would be in violation of state or federal
law.
(b)
Standards for Basic ("Core") Benefits Common to All Benefit Plans.
Every issuer shall make available a policy or certificate including only the
following basic "core" package of benefits to each prospective insured. An
issuer may make available to prospective insureds any of the other Medicare
Supplement Insurance Benefit Plans in addition to the basic "core" package, but
not in lieu thereof.
(1) Coverage of Part A
Medicare Eligible Expenses for hospitalization to the extent not covered by
Medicare from the 61st day through the 90th day in any Medicare benefit
period;
(2) Coverage of Part A
Medicare Eligible Expenses incurred for hospitalization to the extent not
covered by Medicare for each Medicare lifetime inpatient reserve day
used;
(3) Upon exhaustion of the
Medicare hospital inpatient coverage including the lifetime reserve days,
coverage of one hundred percent (100%) of the Medicare Part A eligible expenses
for hospitalization paid at the applicable prospective payment system (PPS)
rate, or other appropriate Medicare standard of payment, subject to a lifetime
maximum benefit of an additional 365 days. The provider shall accept the
issuer's payment as payment in full and may not bill the insured for any
balance;
(4) Coverage under
Medicare Parts A and B for the reasonable cost of the first three (3) pints of
blood (or equivalent quantities of packed red blood cells, as defined under
federal regulations) unless replaced in accordance with federal
regulations;
(5) Coverage for the
coinsurance amount, or in the case of hospital outpatient department services
paid under a prospective payment system, the copayment amount, of Medicare
Eligible Expenses under Part B regardless of hospital confinement, subject to
the Medicare Part B deductible.
(c)
Standards for Additional
Benefits. The following additional benefits shall be included in
Medicare Supplement Benefit Plans "B" through "J" only as provided by section
38a-495a-6
of the Regulations of Connecticut State Agencies.
(1) Medicare Part A Deductible: Coverage for
all of the Medicare Part A inpatient hospital deductible amount per benefit
period.
(2) Skilled Nursing
Facility Care: Coverage for the actual billed charges up to the coinsurance
amount from the 21st day through the 100th day in a Medicare benefit period for
posthospital skilled nursing facility care eligible under Medicare Part
A.
(3) Medicare Part B Deductible:
Coverage for all of the Medicare Part B deductible amount per calendar year
regardless of hospital confinement.
(4) Eighty Percent (80%) of the Medicare Part
B Excess Charges: Coverage for eighty percent (80%) of the difference between
the actual Medicare Part B charge as billed, not to exceed any charge
limitation established by the Medicare program or state law, and the
Medicare-approved Part B charge.
(5) One Hundred Percent (100%) of the
Medicare Part B Excess Charges: Coverage for all of the difference between the
actual Medicare Part B charge as billed, not to exceed any charge limitation
established by the Medicare program or state law, and the Medicare-approved
Part B charge.
(6) Basic Outpatient
Prescription Drug Benefit: Coverage for fifty percent (50%) of outpatient
prescription drug charges, after a two hundred fifty dollar ($250) calendar
year deductible, to a maximum of one thousand two hundred fifty dollars
($1,250) in benefits received by the insured per calendar year, to the extent
not covered by Medicare. The outpatient prescription drug benefit may be
included for new sales in a Medicare supplement policy no later than December
31, 2005.
(7) Extended Outpatient
Prescription Drug Benefit: Coverage for fifty percent (50%) of outpatient
prescription drug charges, after a two hundred fifty dollar ($250) calendar
year deductible to a maximum of three thousand dollars ($3,000) in benefits
received by the insured per calendar year, to the extent not covered by
Medicare. The outpatient prescription drug benefit may be included for new
sales in a Medicare supplement policy no later than December 31,
2005.
(8) Medically Necessary
Emergency Care in a Foreign Country: Coverage to the extent not covered by
Medicare for eighty percent (80%) of the billed charges for Medicare-eligible
expenses for medically necessary emergency hospital, physician and medical care
received in a foreign country, which care would have been covered by Medicare
if provided in the United States and which care began during the first sixty
(60) consecutive days of each trip outside the United States, subject to a
calendar year deductible of two hundred fifty dollars ($250), and a lifetime
maximum benefit of fifty thousand dollars ($50,000). For purposes of this
benefit, "emergency care" shall mean care needed immediately because of an
injury or an illness of sudden and unexpected onset.
(9)
(A)
Preventive Medical Care Benefit: Coverage for the following preventive health
services:
(i) An annual clinical preventive
medical history and physical examination that may include tests and services
from Subparagraph (B) of this subdivision and patient education to address
preventive health care measures.
(ii) Preventive screening tests or preventive
services, the selection and frequency of which is determined by the attending
physician.
(B)
Reimbursement shall be for the actual charges up to one hundred percent (100%)
of the Medicare-approved amount for each service, as if Medicare were to cover
the service as identified in American Medical Association Current Procedural
Terminology (AMA CPT) codes, to a maximum of one hundred twenty dollars ($120)
annually under this benefit. This benefit shall not include payment for any
procedure covered by Medicare.
(10) At-Home Recovery Benefit: Coverage for
services to provide short term, at-home assistance with activities of daily
living for those recovering from an illness, injury or surgery.
(A) For purposes of this benefit, the
following definitions shall apply:
(i)
"Activities of daily living" include, but are not limited to bathing, dressing,
personal hygiene, transferring, eating, ambulating, assistance with drugs that
are normally self-administered, and changing bandages or other
dressings.
(ii) "Care provider"
means a duly qualified or licensed home health aide/homemaker, personal care
aide or nurse provided through a licensed home health care agency or referred
by a licensed referral agency or licensed nurses registry.
(iii) "Home" shall mean any place used by the
insured as a place of residence, provided that such place would qualify as a
residence for home health care services covered by Medicare. A hospital or
skilled nursing facility shall not be considered the insured's place of
residence.
(iv) "At-home recovery
visit" means the period of a visit required to provide at home recovery care,
without limit on the duration of the visit, except each consecutive 4 hours in
a 24-hour period of services provided by a care provider is one
visit.
(B) Coverage
Requirements and Limitations.
(i) At-home
recovery services provided shall be primarily services which assist in
activities of daily living.
(ii)
The insured's attending physician shall certify that the specific type and
frequency of at-home recovery services are necessary because of a condition for
which a home care plan of treatment was approved by Medicare.
(iii) Coverage is limited to:
(I) No more than the number and type of
at-home recovery visits certified as necessary by the insured's attending
physician. The total number of at-home recovery visits shall not exceed the
number of Medicare approved home health care visits under a Medicare approved
home care plan of treatment;
(II)
The actual charges for each visit up to a maximum reimbursement of forty
dollars ($40) per visit;
(III) One
thousand six hundred dollars ($1,600) per calendar year;
(IV) Seven (7) visits in any one
week;
(V) Care furnished on a
visiting basis in the insured's home;
(VI) Services provided by a care provider as
defined in this section;
(VII)
At-home recovery visits while the insured is covered under the policy or
certificate and not otherwise excluded;
(VIII) At-home recovery visits received
during the period the insured is receiving Medicare approved home care services
or no more than eight (8) weeks after the service date of the last Medicare
approved home health care visit.
(C) Coverage is excluded for:
(i) Home care visits paid for by Medicare or
other government programs; and
(ii)
Care provided by family members, unpaid volunteers or providers who are not
care providers.
(d) Standards for Plans K and L.
(1) Standardized Medicare supplement benefit
plan "K" shall consist of the following:
(A)
Coverage of one hundred percent (100%)of the Part A hospital coinsurance amount
for each day used from the 61st through the
90th day in any Medicare benefit period;
(B) Coverage of one hundred percent (100%) of
the Part A hospital coinsurance amount for each Medicare lifetime inpatient
reserve day used from the 91st through the
150th day in any Medicare benefit period;
(C) Upon exhaustion of the Medicare hospital
inpatient coverage, including the lifetime reserve days, coverage of one
hundred percent (100%) of the Medicare Part A eligible expenses for
hospitalization paid at the applicable prospective payment system (PPS) rate,
or other appropriate Medicare standard of payment, subject to a lifetime
maximum benefit of an additional 365 days. The provider shall accept the
issuer's payment as payment in full and may not bill the insured for any
balance;
(D) Medicare Part A
deductible: Coverage for fifty percent (50%) of the Medicare Part A inpatient
hospital deductible amount per benefit period until the out-of-pocket
limitation is met as described in subparagraph (J) of this
subdivision;
(E) Skilled Nursing
Facility Care: Coverage for fifty percent (50%) of the coinsurance amount for
each day used from the 21st day through the
100th day in a Medicare benefit period for
post-hospital skilled nursing facility care eligible under Medicare Part A
until the out-of-pocket limitation is met as described in subparagraph (J) of
this subdivision;
(F) Hospice Care:
Coverage for fifty percent (50%) of cost sharing for all Part A Medicare
eligible expenses and respite care until the out-of-pocket limitation is met as
described in subparagraph (J) of this subdivision;
(G) Coverage for fifty percent (50%), under
Medicare Part A or B, of the reasonable cost of the first three (3) pints of
blood (or equivalent quantities of packed red blood cells, as defined under
federal regulations) unless replaced in accordance with federal regulations
until the out-of-pocket limitation is met as described in subparagraph (J) of
this subdivision;
(H) Except for
coverage provided in subparagraph (I) of this subdivision, coverage for fifty
percent (50%) of the cost sharing otherwise applicable under Medicare Part B
after the policyholder pays the Part B deductible until the out-of-pocket
limitation is met as described in subparagraph (J) of this
subdivision;
(I) Coverage of one
hundred percent (100%) of the cost sharing for Medicare Part B preventive
services after the policyholder pays the Part B deductible; and
(J) Coverage of one hundred percent (100%) of
all cost sharing under Medicare Parts A and B for the balance of the calendar
year after the individual has reached the out-of-pocket limitation on annual
expenditures under Medicare Parts A and B of $4000 in 2006, indexed each year
by the appropriate inflation adjustment specified by the secretary.
(2) Standardized Medicare
supplement benefit plan "L" shall consist of the following:
(A) Coverage of one hundred percent (100%)of
the Part A hospital coinsurance amount for each day used from the
61st through the 90th day
in any Medicare benefit period;
(B)
Coverage of one hundred percent (100%) of the Part A hospital coinsurance
amount for each Medicare lifetime inpatient reserve day used from the
91st through the 150th
day in any Medicare benefit period;
(C) Upon exhaustion of the Medicare hospital
inpatient coverage, including the lifetime reserve days, coverage of one
hundred percent (100%) of the Medicare Part A eligible expenses for
hospitalization paid at the applicable prospective payment system (PPS) rate,
or other appropriate Medicare standard of payment, subject to a lifetime
maximum benefit of an additional 365 days. The provider shall accept the
issuer's payment as payment in full and may not bill the insured for any
balance;
(D) Medicare Part A
deductible: Coverage for seventy-five percent (75%) of the Medicare Part A
inpatient hospital deductible amount per benefit period until the out-of-pocket
limitation is met as described in subparagraph (J) of this
subdivision;
(E) Skilled Nursing
Facility Care: Coverage for seventy-five percent (75%)of the coinsurance amount
for each day used from the 21st day through the
100th day in a Medicare benefit period for
post-hospital skilled nursing facility care eligible under Medicare Part A
until the out-of-pocket limitation is met as described in subparagraph (J) of
this subdivision;
(F) Hospice Care:
Coverage for seventy-five percent (75%) of cost sharing for all Part A Medicare
eligible expenses and respite care until the out-of-pocket limitation is met as
described in subparagraph (J) of this subdivision;
(G) Coverage for seventy-five percent (75%),
under Medicare Part A or B, of the reasonable cost of the first three (3) pints
of blood (or equivalent quantities of packed red blood cells, as defined under
federal regulations) unless replaced in accordance with federal regulations
until the out-of-pocket limitation is met as described in subparagraph (J) of
this subdivision;
(H) Except for
coverage provided in subparagraph (I) of this subdivision, coverage for
seventy-five percent (75%) of the cost sharing otherwise applicable under
Medicare Part B after the policyholder pays the Part B deductible until the
out-of-pocket limitation is met as described in subparagraph (J) of this
subdivision;
(I) Coverage of one
hundred percent (100%) of the cost sharing for Medicare Part B preventive
services after the policyholder pays the Part B deductible; and
(J) Coverage of one hundred percent (100%) of
all cost sharing under Medicare Parts A and B for the balance of the calendar
year after the individual has reached the out-of-pocket limitation on annual
expenditures under Medicare Parts A and B of $2000 in 2006, indexed each year
by the appropriate inflation adjustment specified by the secretary.
Notes
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