The standards established in this section 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 on or
after June 1, 2010 unless it complies with benefit standards established in
this section. No issuer may offer any 1992 Medicare standardized Medicare
supplement benefit plan for sale on or after June 1, 2010. Benefit standards
applicable to Medicare supplement policies and certificates issued with an
effective date for coverage on or after July 30, 1992, and before June 1, 2010,
remain subject to the requirements of 38a-495a-5 and 38a-495a-6 of the
Regulations of Connecticut State Agencies.
(a)
General Standards. The
standards established in this subsection apply to Medicare supplement policies
and certificates delivered or issued for delivery in this state with an
effective date for coverage on or after June 1, 2010 and are in addition to all
other requirements of sections
38a-495a-1
to
38a-495a-21,
inclusive, of the Regulations of Connecticut State Agencies.
(1) 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.
(2) A Medicare supplement policy or
certificate shall not indemnify against losses resulting from sickness on a
different basis than losses resulting from accidents.
(3) A Medicare supplement policy or
certificate shall provide that benefits designed to cover cost sharing amounts
under Medicare will be changed automatically to coincide with any changes in
the applicable Medicare deductible, copayment, or coinsurance amounts. Premiums
may be modified to correspond with such changes.
(4) No Medicare supplement policy or
certificate shall provide for termination of coverage of a spouse solely
because of the occurrence of an event specified for termination of coverage of
the insured, other than the nonpayment of premium.
(5) Each Medicare supplement policy shall be
guaranteed renewable.
(A) The issuer shall not
cancel or nonrenew the policy solely on the ground of health status of the
individual.
(B) The issuer shall
not cancel or nonrenew the policy for any reason other than nonpayment of
premium or material misrepresentation.
(C) If a Medicare supplement policy is
terminated by a group policyholder and is not replaced as provided under
subparagraph (E) of this subdivision of this section, 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 benefits that otherwise
meet 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 offer the certificateholder (i) the conversion
opportunity described in subparagraph (C) of this subdivision, or (ii) at the
option of the group policyholder, 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)
(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 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, provided the policyholder or certificateholder notifies the
issuer of the policy or certificate not later than ninety days after the date
the individual becomes entitled to assistance.
(B) If such suspension occurs and the
policyholder or certificateholder loses entitlement to medical assistance under
Title XIX of the Social Security Act, the policy or certificate shall be
automatically reinstituted effective as of the date of termination of
entitlement provided the policyholder or certificateholder provides notice of
loss of entitlement not later than ninety days after the date of loss and pays
the premium attributable to the period.
(C) Each Medicare supplement policy shall
provide that benefits and premiums under the policy shall be suspended, for any
period that may be provided by federal regulation, at the request of the
policyholder if the policyholder is entitled to benefits under section 226(b)
of the Social Security Act and is covered under a group health plan, as defined
in section 1862(b)(1)(A)(v) of the Social Security Act. If such suspension
occurs and 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, provided the policyholder provides notice of loss of
coverage not later than ninety days after the date of the loss and pays the
premium attributable to the period as of the date of termination of enrollment
in the group health plan.
(D)
Reinstitution of coverages as set forth in subparagraphs (B) and (C) of this
subdivision shall:
(i) Not provide for any
waiting period with respect to treatment of preexisting conditions;
(ii) Provide for resumption of coverage that
is substantially equivalent to the coverage that was in effect before the date
of suspension; and
(iii) Provide
for classification of premiums on terms at least as favorable to the
policyholder or certificate holder as the premium classification terms that
would have applied to the policyholder or certificate holder had the coverage
not been suspended.
(b)
Standards for Basic Core Benefits
Common to Medicare Supplement 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 that includes only the following
basic core package of benefits to each prospective insured. An issuer may make
available to prospective insureds any of the other Medicare supplement
insurance benefit plans in addition to the basic core package, but not in lieu
of it
(1) Coverage of Part A Medicare
eligible expenses for hospitalization to the extent not covered by Medicare
from the 61st day through the
90th day in any Medicare benefit period;
(2) Coverage of Part A Medicare eligible
expenses incurred for hospitalization to the extent not covered by Medicare for
each Medicare lifetime inpatient reserve day used;
(3) Upon exhaustion of the Medicare hospital
inpatient coverage, including the lifetime reserve days, coverage of one
hundred percent 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 pints of blood, or equivalent quantities
of packed red blood cells, as defined under federal regulations, unless
replaced in accordance with federal regulations;
(5) Coverage for the coinsurance amount, or
in the case of hospital outpatient department services paid under a prospective
payment system, the copayment amount, of Medicare eligible expenses under Part
B regardless of hospital confinement, subject to the Medicare Part B
deductible;
(6) Hospice Care:
coverage of cost sharing for all Part A Medicare eligible hospice care and
respite care expenses.
(c)
Standards for Additional Benefits.
The following additional benefits shall be included in Medicare
supplement benefit plans B, C, D, F, F with High Deductible, G, M, and N as set
forth in section
38a-495a-6
a of the Regulations of Connecticut State Agencies:
(1) Medicare Part A Deductible: Coverage for
100 percent of the Medicare Part A inpatient hospital deductible amount per
benefit period;
(2) Medicare Part A
Deductible: Coverage for fifty percent of the Medicare Part A inpatient
hospital deductible amount per benefit period;
(3) Skilled Nursing Facility Care: Coverage
for the actual billed charges up to the coinsurance amount from the
21st day through the
100th day in a Medicare benefit period for
post-hospital skilled nursing facility care eligible under Medicare Part
A;
(4) Medicare Part B Deductible:
Coverage for one hundred percent of the Medicare Part B deductible amount per
calendar year regardless of hospital confinement;
(5) One Hundred Percent of the Medicare Part
B Excess Charges: Coverage for all of the difference between the actual
Medicare Part B charges as billed, not to exceed any charge limitation
established by the Medicare program or state law, and the Medicare approved
Part B charge;
(6) Medically
Necessary Emergency Care in a Foreign Country: Coverage to the extent not
covered by Medicare for eighty percent 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 $250 and a lifetime maximum benefit of
$50,000. For purposes of this benefit, "emergency care" means care needed
immediately because of an injury or an illness of sudden and unexpected
onset.