The following standards are applicable to all Medicare
supplement policies or certificates delivered or issued for delivery in this
state on or after September 30, 2005 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 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 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.
(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) 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.
1. The issuer shall not
cancel or nonrenew the policy solely on the ground of health status of the
individual;
2. The issuer shall not
cancel or nonrenew the policy for any reason other than nonpayment of premium
or material misrepresentation;
3.
If the Medicare supplement policy is terminated by the group policyholder and
is not replaced as provided under Section 8(1)(e)5., the issuer shall offer
certificateholders an individual Medicare supplement policy that (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.
4. 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 Section 8(1)(e)3.,
or
(ii) At the option of the group
policyholder, offer the certificateholder continuation of coverage under the
group policy.
5. 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. If a Medicare supplement policy eliminates
an outpatient prescription drug benefit as a result of requirements imposed by
the Medicare Prescription Drug, Improvement and Modernization Act of 2003, the
modified policy shall be deemed to satisfy the guaranteed renewal requirements
of this paragraph.
(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 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)
1. 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
the policy or certificate within ninety (90) days after the date the individual
becomes entitled to assistance.
2.
If suspension occurs and if the policyholder or certificateholder loses
entitlement to medical assistance, the policy or certificate shall be
automatically reinstituted effective as of the date of termination of
entitlement if the policyholder or certificateholder provides notice of loss of
entitlement within ninety (90) days after the date of loss and pays the premium
attributable to the period.
3. 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 (90) days
after the date of the loss and pays the premium attributable to the period,
effective as of the date of termination of enrollment in the group health
plan.
4. Reinstitution of coverages
as described in Subparagraphs 2. and 3.:
(i)
Shall not provide for any waiting period with respect to treatment of
preexisting conditions;
(ii) Shall
provide for resumption of coverage that is substantially equivalent to coverage
in effect before the date of suspension. 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.
(h) 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 from his or her 1990 Standardized
plan (as described in Section
120-2-8-.09 of this regulation) to a
2010 Standardized plan (as described in Section
120-2-8-.09(8) of
this regulation), the offer and subsequent exchange shall comply with the
following requirements:
1. An issuer need not
provide justification to the Commissioner 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. 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 pre-funding
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
Commissioner.
2. The rating class
of the new policy or certificate shall be the class closest to the insured's
class of the replaced coverage.
3.
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 (6) months to any added
benefits contained in the new 2010 Standardized policy or certificate not
contained in the exchanged policy.
4. 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.
(2)
Standards for Basic (Core) Benefits Common to Benefit Plans A to J. Every
issuer shall make available a policy or certificate including only the
following basic "core" package of benefits to each prospective insured. An
issuer may make available to prospective insureds any of the other Medicare
Supplement Insurance Benefit Plans in addition to the basic core package, but
not in lieu of it.
(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 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 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) 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;
(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 Section
120-2-8-.09 of this regulation.
(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 21st day through the 100th 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 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.
(e) 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.
(f) Basic Outpatient
Prescription Drug Benefit: Coverage for fifty percent (50%) of outpatient
prescription drug charges, after a $250 calendar year deductible, to a maximum
of $1,250 in benefits received by the insured per calendar year, to the extent
not covered by Medicare. The outpatient prescription drug benefit may be
included for sale or issuance in a Medicare supplement policy until January 1,
2006.
(g) Extended Outpatient
Prescription Drug Benefit: Coverage for fifty percent (50%) of outpatient
prescription drug charges, after a $250 calendar year deductible to a maximum
of $3,000 in benefits received by the insured per calendar year, to the extent
not covered by Medicare. The outpatient prescription drug benefit may be
included for sale or issuance in a Medicare supplement policy until January 1,
2006.
(h) Medically Necessary
Emergency Care in a Foreign Country: Coverage to the extent not covered by
Medicare for eighty percent (80%) of the billed charges for Medicare-eligible
expenses for medically necessary emergency hospital, physician and medical care
received in a foreign country, which care would have been covered by Medicare
if provided in the United States and which care began during the first sixty
(60) consecutive days of each trip outside the United States, subject to a
calendar year deductible of $250, and a lifetime maximum benefit of $50,000.
For purposes of this benefit, "emergency care" shall mean care needed
immediately because of an injury or an illness of sudden and unexpected
onset.
(i)
1. 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
Subparagraph (ii) 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.
2. 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 $120 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.
1. For purposes of
this benefit, the following definitions shall apply:
(i) "Activities of daily living" include, but
are not limited to bathing, dressing, personal hygiene, transferring, eating,
ambulating, assistance with drugs that are normally self-administered, and
changing bandages or other dressings.
(ii) "Care provider" means a duly qualified
or licensed home health aide or homemaker, personal care aide or nurse provided
through a licensed home health care agency or referred by a licensed referral
agency or licensed nurses registry.
(iii) "Home" shall mean any place used by the
insured as a place of residence, provided that the 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 four (4)
hours in a twenty-four-hour period of services provided by a care provider is
one visit.
2. Coverage
Requirements and Limitations.
(i) At-home
recovery services provided must be primarily services which assist in
activities of daily living.
(ii)
The insured's attending physician must certify that the specific type and
frequency of at-home recovery services are necessary because of a condition for
which a home care plan of treatment was approved by Medicare.
(iii) Coverage is limited to:
(I) No more than the number and type of
at-home recovery visits certified as necessary by the insured's attending
physician. The total number of at-home recovery visits shall not exceed the
number of Medicare approved home health care visits under a Medicare approved
home care plan of treatment;
(II)
The actual charges for each visit up to a maximum reimbursement of $40 per
visit;
(III) $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.
3. 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.
(4) Standards for Plans K and L.
(a) Standardized Medicare supplement benefit
plan "K" shall consist of the following:
1.
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;
2. 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;
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. 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 10.;
5. 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 10.;
6. 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
10.;
7. 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 10.;
8. Except for
coverage provided in Subparagraph 9. below, 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 10. below;
9. 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
10.
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 of the U.S. Department of Health and Human
Services.
(b)
Standardized Medicare supplement benefit plan "L" shall consist of the
following:
1. The benefits described in
Paragraphs (a)1., 2., 3. and 9.;
2.
The benefit described in Paragraphs (a)4., 5., 6., 7. and 8., but substituting
seventy-five percent (75%) for fifty percent (50%); and
3. The benefit described in Paragraph (a)10.,
but substituting $2000 for $4000.
(5) Benefit Standards for 2010 Standardized
Medicare Supplement Benefit Plan Policies or Certificates 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 unless it complies with these
benefit standards. No issuer may offer any 1990 Standardized Medicare
supplement benefit plan for sale on or after June 1, 2010. Benefit standards
applicable to Medicare supplement policies and certificates issued with an
effective date for coverage before June 1, 2010 remain subject to the
requirements of Rule
120-2-8-.08.
(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.
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.
(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
Section
120-2-8-.08(5)(a)
5.(v) of this regulation, 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.
(iv) 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 Section
120-2-8-.08(5)(a)5.(iii)
of this regulation; or
(II) At the
option of the group policyholder, offer the certificateholder 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.
(vi) 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.
(vii)
(I)
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 the policy or certificate within ninety (90) days after the date
the individual becomes entitled to assistance.
(II) If suspension occurs and if the
policyholder or certificateholder 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 certificateholder provides notice of loss of entitlement within
ninety (90) 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 (90) days after the date of the loss.
(IV) Reinstitution of coverages as described
in Subparagraphs (ii) and (iii):
I. Shall not
provide for any waiting period with respect to treatment of preexisting
conditions;
II. Shall provide for
resumption of coverage that is substantially equivalent to coverage in effect
before the date of suspension; and
III. Shall provide for classification of
premiums on terms at least as favorable to the policyholder or
certificateholder as the premium classification terms that would have applied
to the policyholder or certificateholder had the coverage not been
suspended.
(b) Standards for Basic (Core) Benefits
Common to Medicare Supplement Insurance Benefit Plans A, B, C, D, F, F with
High Deductible, G, M and N. Every issuer of Medicare supplement insurance
benefit plans shall make available a policy or certificate including only the
following basic "core" package of benefits to each prospective insured. An
issuer may make 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 (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;
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 provided by Section
120-2-8-.09(8) of
this regulation. Benefits for Plans K and L are set by The Medicare
Prescription Drug, Improvement and Modernization Act of 2003, and can be found
in Rule Sections
120-2-8-.09(8)(e) 8. and
9. of this regulation.
1. Medicare Part A Deductible: Coverage for
one hundred percent (100%) of the Medicare Part A inpatient hospital deductible
amount per benefit period.
2.
Medicare Part A Deductible: Coverage for fifty percent (50%) of the Medicare
Part A inpatient hospital deductible amount per benefit period.
3. Skilled Nursing Facility Care: Coverage
for the actual billed charges up to the coinsurance amount from the 21st day
through the 100th day in a Medicare benefit period for post-hospital skilled
nursing facility care eligible under Medicare Part A.
4. Medicare Part B Deductible: Coverage for
one hundred percent (100%) of the Medicare Part B deductible amount per
calendar year regardless of hospital confinement.
5. One Hundred Percent (100%) of the Medicare
Part B Excess Charges: Coverage for all of the difference between the actual
Medicare Part B charges as billed, not to exceed any charge limitation
established by the Medicare program or state law, and the Medicare-approved
Part B charge.
6. Medically
Necessary Emergency Care in a Foreign Country: Coverage to the extent not
covered by Medicare for eighty percent (80%) of the billed charges for
Medicare-eligible expenses for medically necessary emergency hospital,
physician and medical care received in a foreign country, which care would have
been covered by Medicare if provided in the United States and which care began
during the first sixty (60) consecutive days of each trip outside the United
States, subject to a calendar year deductible of $250, and a lifetime maximum
benefit of $50,000. For purposes of this benefit, "emergency care" shall mean
care needed immediately because of an injury or an illness of sudden and
unexpected onset.
Notes
Ga. Comp. R.
& Regs. R. 120-2-8-.08
O.C.G.A. Secs.
33-2-9,
33-43-3 to
33-43-6.
Original Rule entitled
"Required Disclosure Provisions" adopted. F. Oct.
28, 1980; eff. Nov. 17,
1980.
Repealed: New Rule entitled "Standards for Claims
Payment" adopted. F. Aug. 24, 1989; eff.
Sept. 15, 1989.
Repealed: New Rule entitled "Minimum Benefit
Standards" adopted. F. Sept. 18, 1990;
eff. Dec. 1, 1990, as specified
by the Agency.
Repealed: New Rule entitled "Benefit Standards for
Policies or Certificates Issued or Delivered on or After the Effective Date of
this Regulation" adopted. F. July 9, 1992;
eff. July 29, 1992.
Amended: ER. 120-2-8-0.4-.08 entitled "Benefit
Standards for Policies or Certificates Issued for Delivery on or After the
Effective Date of this Regulation" adopted. F. Apr.
30, 1996; eff. Apr. 28,
1996, as specified by the Agency.
Amended: Permanent Rule of same title adopted. F.
Sept. 6, 1996; eff.
Sept. 26, 1996.
Repealed: New Rule entitled "Benefit Standards for
Policies or Certificates Issued for Delivery on or After the Effective Date of
this Regulation" adopted. F. Apr. 7, 1999;
eff. Apr. 27, 1999.
Repealed: New Rule of same title adopted. F.
Aug. 19, 2005; eff.
Sept. 8, 2005.
Amended: ER. 120-2-8-0.22-.08 entitled "Benefit
Standards for 1990 Standardized Medicare Supplement Benefit Plan Policies or
Certificates Issued or Delivered on or After September 30, 2005 and Prior to
June 1, 2010" adopted. F. May 29, 2009;
eff. June 1, 2009, as specified
by the Agency.
Repealed: New Rule entitled "Benefit Standards for
1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates
Issued or Delivered on or After September 30, 2005 and with an Effective Date
for Coverage Prior to June 1, 2010" adopted. F. Sept.
3, 2009; eff. Sept. 23,
2009.