Ga. Comp. R. & Regs. R. 120-2-8-.07 - Minimum Benefit Standards for Pre-Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery Prior to the Effective Date of This Regulation
No policy or certificate may be advertised, solicited or issued for delivery in this state as a Medicare supplement policy or certificate unless it meets or exceeds the following minimum standards. These are minimum standards and do not preclude the inclusion of other provisions or benefits that 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 regulation.
(a) A Medicare supplement policy or
certificate shall not exclude or limit benefits for losses incurred more than
six (6) months from the effective date of coverage because it involved a
preexisting condition. The policy or certificate shall not define a preexisting
condition more restrictively than a condition for which medical advice was
given or treatment was recommended by or received from a physician within six
(6) months before the effective date of coverage.
(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 through filings as otherwise provided within this Regulation
Chapter to correspond with such changes.
(d) A "noncancellable," "guaranteed
renewable," or "noncancellable and guaranteed renewable" Medicare supplement
policy shall not:
1. Provide for termination
of coverage of a spouse solely because of the occurrence of an event specified
for termination of coverage of the insured, other than the nonpayment of
premium; or
2. Be cancelled or
nonrenewed by the issuer solely on the grounds of deterioration of
health.
(e)
1. Except as authorized by the Commissioner
of Insurance of this State, an issuer shall neither cancel nor nonrenew a
Medicare supplement policy or certificate for any reason other than nonpayment
of premium or material misrepresentation.
2. If a group Medicare supplement insurance
policy is terminated by the group policyholder and not replaced as provided in
Paragraph (e)4., the issuer shall offer certificateholders an individual
Medicare supplement policy. The issuer shall offer the certificateholder at
least the following choices:
(i) An individual
Medicare supplement policy currently offered by the issuer having comparable
benefits to those contained in the terminated group Medicare supplement policy;
and
(ii) An individual Medicare
supplement policy that provides only such benefits as are required to meet the
minimum standards as defined in Section
120-2-8-.08(5)(b)
of this regulation.
3.
If membership in a group is terminated, the issuer shall:
(i) Offer the certificateholder the
conversion opportunities described in Subparagraph (ii); or
(ii) At the option of the group policyholder,
offer the certificateholder continuation of coverage under the group
policy.
4. If a group
Medicare supplement policy is replaced by another group Medicare supplement
policy purchased by the same policyholder, the issuer of the replacement policy
shall offer coverage to all persons covered under the old group policy on its
date of termination. Coverage under the new group policy shall not result in
any exclusion for preexisting conditions that would have been covered under the
group policy being replaced.
(f) Termination of a Medicare supplement
policy or certificate shall be without prejudice to any continuous loss that
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 this subsection.
(2) Minimum Benefit Standards.
(a) 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;
(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 ninety
percent (90%) of all Medicare Part A eligible expenses for hospitalization not
covered by Medicare subject to a lifetime maximum benefit of an additional 365
days;
(e) Coverage under Medicare
Part A for the reasonable cost of the first three (3) pints of blood (or
equivalent quantities of packed red blood cells, as defined under federal
regulations) unless replaced in accordance with federal regulations or already
paid for under Part B;
(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 [$100];
(g)
Effective January 1, 1990, coverage under Medicare Part B for the reasonable
cost of the first three (3) pints of blood (or equivalent quantities of packed
red blood cells, as defined under federal regulations), unless replaced in
accordance with federal regulations or already paid for under Part A, subject
to the Medicare deductible amount.
Notes
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