CHAPTER Ins 1900 ACCIDENT AND HEALTH INSURANCE

PART Ins 1901 MINIMUM STANDARDS FOR ACCIDENT AND HEALTH INSURANCE - EXPIRED

Source. (See Revision Note at chapter heading for Ins 6000)

PART Ins 1902 MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES ISSUED PRIOR TO ADOPTION OF INSURANCE REGULATION 1905

Statutory Authority: RSA 400-A:15 II

Ins 1902.01 Purpose. The purpose of this part is to provide for the reasonable standardization of coverage and simplification of benefits of medicare supplement accident and sickness insurance policies and medicare supplement subscriber contracts in order to facilitate the public understanding and comparison and to eliminate provisions contained in such policies or contracts which may be misleading or confusing in connection either with the purchase of such policies or with the settlement of claims and to provide for full disclosures in the sale of such coverage.

Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5656, eff 7-1-93, EXPIRED: 7-1-99

New. #8555, eff 2-1-06, EXPIRED: 2-1-14

New. #11014, eff 1-8-16

Ins 1902.02 Applicability And Scope.

(a) Except as provided in paragraph (b) this part shall apply to:

(1) All medicare supplement policies and subscriber contracts advertised, solicited, delivered or issued for delivery in this state prior to July 1, 1992; and

(2) All certificates issued under group medicare supplement policies or subscriber contracts, which policies or contracts have been advertised, solicited, delivered, or issued for delivery in this state prior to July 1, 1992.

(b) This part shall not apply to policies or contracts:

(1) Of one or more employers or labor organizations;

(2) Of the trustees of a fund established by one or more employers or labor organizations, or a combination thereof;

(3) For employees or former employees, or a combination thereof;

(4) For members or former members, or a combination thereof, of the labor organizations; or

(5) Medicare supplement policies and certificates subject to Ins 1905.

Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99

New. #8555, eff 2-1-06, EXPIRED: 2-1-14

New. #11014, eff 1-8-16

Ins 1902.03 Definitions.

(a) "Applicant" means:

(1) In the case of an individual medicare supplement policy or subscriber contract, the person who seeks to contract for insurance benefits; and

(2) In the case of a group medicare supplement policy or subscriber contract, the proposed certificateholder.

(b) "Certificate" means any certificate issued under a group medicare supplement policy, which policy has been advertised, solicited, delivered, or issued for delivery in this state.

(c) "Medicare supplement policy" means a group or individual policy of accident and health insurance or a subscriber contract of hospital service corporations, medical service corporations, or health service corporations 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 and includes:

(1) A policy or contract for one or more employers or labor organizations, or of the trustees of a fund established by one or more employers or labor organizations, or a combination thereof, for employees or former employees, or combination thereof, or for members or former members, or combination thereof, of the labor organizations; or

(2) A policy or contract of any professional, trade, or occupational association for its members or former or retired members, or a combination thereof, if such association:

a. Is composed of individuals all of whom are actively engaged in the same profession, trade, or occupation;

b. Has been maintained in good faith for purposes other than obtaining insurance; and

c. Has been in existence for at least 2 years prior to the date of its initial offering of such policy or plan to its members.

(d) "Medicare" means the "Health Insurance For The Aged Act," Title XVIII of the Social Security Amendments of 1965, as then constituted or later amended.

Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5119, eff 4-25-91; amd by #5421, eff 7-1-92; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED:10-29-99

New. #8555, eff 2-1-06, EXPIRED: 2-1-14

New. #11014, eff 1-8-16

Ins 1902.04 Policy Definitions And Terms. No medicare supplement policy subject to this part shall contain definitions or terms respecting the matters set forth herein unless such definitions or terms conform to the requirements of this section as follows:

(a) "Accident, "accidental injury," or "accidental means" shall be defined to employ "result" language and shall not include words which establish an accidental means test or use words such as "external, violent, visible wounds," or similar words of description or characterization so that:

(1) 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 occurrence while the insurance is in force;” and

(2) The definition may include coverage of injuries for which benefits are provided under any workers' compensation, employer's liability or similar law, motor vehicle no-fault plan, unless prohibited by law.

(b) "Benefit period" or "medicare benefit period" shall not be defined as more restrictive than as that defined in the medicare program.

(c) "Convalescent nursing home," "extended care facility," or "skilled nursing facility" shall be defined in relation to its status, facilities, and available services so that:

(1) A definition of such home or facility shall not be more restrictive than one requiring that it:

a. Be operated pursuant to law;

b. Be approved for payment of medicare benefits or be qualified to receive such approval, if so requested;

c. Be primarily engaged in providing, in addition to room and board accommodations, skilled nursing care under the supervision of a duly licensed physician;

d. Provide continuous 24-hours-a-day nursing service by or under the supervision of a registered graduate professional nurse R.N.; and

e. Maintains a daily medical record of each patient ; and

(2) The definition of such home or facility may provide that such term shall not be inclusive of:

a. Any home, facility, or part thereof used primarily for rest;

b. A home or facility for the aged or for the care of drug addicts or alcoholics; or

c. A home or facility primarily used for the care and treatment of mental diseases, or disorders, or custodial or educational care.

(d) "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 so that:

(1) The definition of the term "hospital" shall not be more restrictive than one requiring that the hospital:

a. Be an institution operated pursuant to law;

b. Be primarily and continuously engaged in providing or operating, either on its premises or in facilities available to the hospital on a prearranged basis and under the supervision of a staff of duly licensed physicians, medical, diagnostic, and major surgical facilities for the medical care and treatment of sick or injured persons on an inpatient basis for which a charge is made; and

c. Provide 24-hour nursing service by or under the supervision of registered graduate professional nurses; and

(2) The definition of the term "hospital" may state that such term shall not be inclusive of:

a. Convalescent homes, convalescent, rest, or nursing facilities;

b. Facilities primarily affording custodial, educational or rehabilitory care;

c. Facilities for the aged, drug addicts, or alcoholics; or

d. Any military or veterans hospital or soldiers home or any hospital contracted for or operated by any national government or agency thereof for the treatment of members or ex-members of the armed forces, except for services rendered on an emergency basis where a legal liability exists for charges made to the individual for such services.

(e) "Medicare" shall be 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 Laws of 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. Medicare consists of Part A and Part B. Part A refers to hospital benefits and Part B refers to Medicaid benefits.

(f) "Issuer" shall be defined as including insurance companies, fraternal benefit societies, nonprofit health service corporations, health maintenance organizations, and any other entity advertising, soliciting, delivering or issuing for delivery in this state medicare supplement policies or certificates.

(g) "Medicare eligible expenses" shall be defined as health care expenses of the kinds covered by medicare, to the extent recognized as reasonable by medicare. Payment of benefits by insurers for medicare eligible expenses may be conditioned upon the same or less restrictive payment conditions, including determinations of medical necessity as are applicable to medicare claims.

(h) "Mental or nervous disorders" shall not be defined more restrictively than a definition including neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder of any kind.

(i) "Nurses" may be defined so that the description of nurse is restricted to a type of nurse, such as a registered graduate professional nurse, R.N., a licensed practical nurse, L.P.N. or a licensed vocational nurse, L.V.N. If the words "nurse," "trained nurse" or "registered nurse" are used without specific instruction, then the insurer shall recognize the services of any individual who qualified under such terminology in accordance with the applicable statutes or administrative rules of the licensing or registry board of the state.

(j) "Physician" may be defined by including words such as "duly qualified physician" or "duly licensed physician." The use of such terms shall require an insurer to recognize and to accept, to the extent of its obligation under the contract, all providers of medical care and treatment when such services are within the scope of the provider's licensed authority and are provided pursuant to applicable laws.

(k) "Preexisting condition" shall be defined as a condition for which medical advice or treatment was recommended by or received from a physician within the 6 month period preceding the effective date of the coverage of the insured person.

(l) "Sickness" shall not be defined to be more restrictive than the following:

(1) Sickness means sickness or disease of an insured person which first manifests itself after the effective date of insurance and while the insurance is in force; and

(2) The definition may be further modified to exclude sickness or disease for which benefits are provided under any workers' compensation, occupational disease, employer's liability, or similar law.

(m) "Health care expenses" shall be defined as expenses of health maintenance organizations associated with the delivery of health care services which are analogous to incurred losses of insurers, but the definition shall not include the following expenses:

(1) Home office and overhead costs;

(2) Advertising costs;

(3) Commissions and other acquisitional costs;

(4) Taxes;

(5) Capital costs;

(6) Administrative costs; or

(7) Claims processing cost.

Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5119, eff 4-25-91; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99

New. #8555, eff 2-1-06, EXPIRED: 2-1-14

New. #11014, eff 1-8-16

Ins 1902.05 Prohibited Policy Provisions.

(a) No medicare supplement policy shall limit or exclude coverage by type of illness, accident, treatment, or medical condition, except as follows:

(1) Foot care in connection with corns, calluses, flat feet, fallen arches, weak feet, chronic foot strain, or symptomatic complaints of the feet;

(2) Alcoholism, drug addiction, and mental or emotional disorders except as provided in RSA 415:18-a; RSA 419:5-a; and RSA 420:5-a;

(3) Illness, treatment, or medical condition arising out of:

a. War or act of war, whether declared or undeclared;

b. Participation in a felony, riot or insurrection;

c. Service in the armed forces or units auxiliary thereto;

d. Suicide, sane or insane, attempted suicide or intentionally self-inflicted injury;

e. Aviation;

(4) Cosmetic surgery, except that "cosmetic surgery" shall not include reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection, other diseases or disorders of the involved part;

(5) Care in connection with the detection and correction by manual or mechanical means of structural imbalance, distortion, or subluxation in the human body for purposes of removing nerve interference and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of, or in the vertebral column;

(6) Treatment provided in a governmental hospital, benefits provided under governmental program, except Medicaid, any state or federal workers' compensation, employers' liability or occupational disease law or any motor vehicle no-fault law, services rendered by employees of hospitals, laboratories or other institutions, services performed by a member of the covered person's immediate family and services for which no charge is normally made in the absence of insurance;

(7) Dental care or treatment;

(8) Eyeglasses, hearing aids, and examinations for the prescription or fitting thereof;

(9) Rest cures, custodial care, transportation, and routine physical examinations; or

(10) Territorial limitations outside the United States provided, however, medicare supplement policies may not contain, when issued, limitations or exclusions of the type enumerated in this paragraph that are more restrictive than those of medicare. Medicare supplement policies may exclude coverage for any expense to the extent of any benefit available to the insured under medicare.

(b) No medicare supplement policy may use waivers to exclude, limit, or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions.

(c) No medicare supplement policy shall include terms which provide that the policy may be cancelled or nonrenewed by the insurer solely on the grounds of deteriorated health.

(d) The terms "medicare supplement," "medigap", and words of similar import shall not be used unless the policy is issued in compliance with this part.

(e) No medicare supplement insurance policy, contract, or certificate in force in this state shall contain benefits which duplicate benefits provided by medicare.

Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5119, eff 4-25-91; amd by #5421, eff 7-1-92; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED:10-29-99

New. #8555, eff 2-1-06, EXPIRED: 2-1-14

New. #11014, eff 1-8-16

Ins 1902.06 Minimum Standards For Medicare Supplement Policies. No policy or certificate shall be advertised, solicited, delivered, or issued for delivery in this state as a medicare supplement policy or certificate unless it meets or exceeds the following minimum standards:

(a) Medicare supplement policies and certificates, advertised, solicited, delivered, or issued for delivery in this state shall comply with the following:

(1) A medicare supplement policy or certificate shall not exclude or limit benefits for losses incurred more than 6 months from the effective date of coverage because it involved a preexisting condition and shall not define a preexisting condition more restrictively than the definition found in Ins 1902.04(k);

(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 amount and co-payment percentage factors. Premiums may be changed to correspond with such benefit changes, but such changes in premiums may not be implemented prior to their approval by the commissioner pursuant to RSA 415:1;

(4) A "noncancellable," "guaranteed renewable," or "noncancellable and guaranteed renewable" medicare supplement policy or certificate shall not 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) The rights of an insured with respect to or upon termination shall be as follows:

a. Except as authorized by the insurance commissioner an issuer shall neither cancel nor nonrenew a medicare supplement policy or certificate for any reason other than nonpayment of premium or material misrepresentation;

b. If a group medicare supplement insurance policy is terminated by the group policyholder and not replaced as provided in Ins 1902.06(a)(5)e., the insurer shall give written notice to certificateholders and offer an individual medicare supplement policy with at least the following choices:

1. An individual medicare supplement policy currently offered by the issuer having comparable benefits to those contained in the terminated group medicare supplement policy; and

2. An individual medicare supplement policy that provides only such benefits as are required to meet the minimum standards as defined in Ins 1902.06(b);

c. If membership in a group is terminated, the issuer shall give written notice and:

1. Offer the certificateholder such conversion opportunities as are described in Ins 1902.06(a)(5)e.; or

2. At the option of the group policyholders, offer the certificateholder continuation of coverage under the group policy;

d. The certificateholder shall have 30 days following receipt of written notice to apply for any conversion policy offered pursuant to this section;

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; and

f. Coverage under the replacement policy shall not result in any exclusion for preexisting conditions that would have been covered under the group policy that was replaced; and

(6) The 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 payment of the maximum benefits.

(b) Medicare supplement policies advertised, solicited, delivered, or issued for delivery in this state shall meet or exceed the following minimum benefit standards:

(1) Coverage of part A medicare eligible expenses for hospitalization to the extent not covered by medicare for the 61st day through the 90th day in any medicare benefit period;

(2) Coverage for either all or none of the medicare part A inpatient hospital deductible amount;

(3) Coverage of part A medicare eligible expenses incurred as daily hospital charges during the use of Medicare’s lifetime hospital inpatient reserve days;

(4) Upon exhaustion of all medicare hospital inpatient coverage including the lifetime reserve days, coverage of 90 percent of all medicare part A eligible expenses for hospitalization not covered by medicare subject to a lifetime maximum benefit of an additional 365 days;

(5) Coverage under medicare part A for the reasonable cost of the first 3 pints of blood or equivalent quantities of packed red blood cells, as defined under 42 CFR Part 409.87 unless replaced in accordance with 42 CFR Part 409.87 or already paid for under part B;

(6) Coverage for coinsurance 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 $100 medicare part B deductible; and

(7) Coverage under medicare part B for the reasonable cost of the first 3 pints of blood or equivalent quantities of packed red blood cells, as defined under 42 CFR Part 409.87 unless replaced in accordance with 42 CFR Part 409.87 or already paid under part A, subject to the medicare deductible amount.

Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5119, eff 4-25-91; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99

New. #8555, eff 2-1-06, EXPIRED: 2-1-14

New. #11014, eff 1-8-16

Ins 1902.07 Required Disclosure Provisions.

(a) All medicare supplement policies shall include the following general rules:

(1) Medicare supplement policies shall include a renewal or continuation provision which shall be consistent with the type of contract issued, captioned, and shall appear on the first page of the policy;

(2) A medicare supplement policy which provides for the payment of benefits based on standards described as "usual and customary," "reasonable and customary," or words of similar import, shall include a definition of such terms and an explanation of such terms in its accompanying outline of coverage;

(3) If a medicare supplement policy contains any limitations with respect to preexisting conditions, such limitations shall appear as a separate paragraph of the policy and be labeled as "preexisting condition limitations";

(4) All medicare supplement policies or certificates shall have a notice prominently printed on the first page of the policy or certificate attached thereto stating that the policyholder or certificateholder shall have the right to return the policy or certificate within 30 days of its delivery and to have the premium refunded if, after examination of the policy or certificate, the insured person is not satisfied for any reason;

(5) Except as otherwise provided in this part, the terms "medicare supplement," "medigap" and words of similar import shall not be used unless the policy is issued in compliance with Ins 1902.06; and

(6) Except for riders or endorsements by which the insurer effectuates a request made in writing by the insured, exercises a specifically reserved right under a medicare supplement policy, or is required to reduce or eliminate benefits to avoid duplication of medicare benefits, all riders or endorsements added to a medicare supplement policy after date of issue or at reinstatement or renewal which reduce or eliminate benefits or coverage in the policy shall require signed acceptance by the insured. After the date of policy issue, any rider or endorsement which increases benefits or coverage with a concomitant increase in premium during the policy term shall be agreed to in writing signed by the insured, unless the benefits are required by the minimum standards for medicare supplement policies, or if the increased benefits or coverage is required by law. Where a separate additional premium is charged for benefits provided in connection with riders or endorsements, such premium charge shall be set forth in the policy.

(b) The following notice requirements shall be met:

(1) As soon as practicable, but not later than 30 days prior to the annual effective date of any medicare benefit changes, every insurer, health care service plan, or other entity providing medicare supplement insurance or benefits to a resident of this state shall notify its policyholders, contractholders and certificateholders of modifications it has made to medicare insurance policies or contracts;

(2) The notice required by (1) above shall:

a. Include a description of revisions to the medicare program and a description of each modification made to the coverage provided under the medicare supplement insurance policy or contract; and

b. Inform each covered person as to when any premium adjustment is to be made due to changes in medicare;

(3) The notice of benefit modifications and any premium adjustments shall be in outline form and in clear and simple terms so as to facilitate comprehension; and

(4) Such notices shall not contain or be accompanied by any solicitation.

(c) Medicare supplement policies shall contain the following information:

(1) Insurers issuing medicare supplement policies or certificates for delivery in this state shall provide an outline of coverage to all applicants at the time application is made and, except for direct response policies, shall obtain an acknowledgment of receipt of such outline from the applicant; and

(2) If an outline of coverage is provided at the time of application and the medicare supplement policy or certificate is issued on a basis which would require revision of the outline, a substitute outline of coverage properly describing the policy or certificate shall accompany such policy or certificate when it is delivered and contain the following statement, in no less than 12 point type, immediately above the company name: "It is not identical to the outline of coverage provided upon application and the coverage originally applied for has not been issued;" and

(3) In addition to the requirements of subparagraphs (1) and (2), insurers issuing medicare supplement policies or certificates shall provide an outline of coverage for such medicare supplement policies or certificates to any prospective purchaser upon request.

(d) Notice regarding policies or subscriber contracts which are not medicare supplement policies shall include:

(1) The following in no less than 12 point type, either printed or attached to the first page of the outline of coverage delivered to insureds under the policy or subscriber contract, or if no outline of coverage is delivered, to the first page of the policy, certificate or subscriber contract delivered to insureds: "This, policy, certificate or subscriber contract, is not a medicare supplement policy or certificate. If you are eligible for medicare, review the medicare supplement buyer's guide available from the company" on the following policies issued for delivery in this state to persons eligible for medicare:

a. Any accident and sickness insurance policy or subscriber contract, other than a medicare supplement policy;

b. A policy issued pursuant to a contract under section 1876 of the Federal Social Security Act 42 U.S.C. Section 1395 et seq., disability income policy;

c. Basic, catastrophic, or major medical expense policy; and

d. Single premium nonrenewable policy or other policy identified in Ins 1902.02(b) of this part.

Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5119, eff 4-25-91; amd by #5421, eff 7-1-92; ss by #5656, eff 7-1-93; amd by #6405, eff 1-1-97; amd by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99

New. #8555, eff 2-1-06, EXPIRED: 2-1-14

New. #11014, eff 1-8-16

Ins 1902.08 Requirements for Application Forms and Replacement Coverage.

(a) Application forms shall include the following questions designed to elicit information as to whether, as of the date of the application, the applicant has another medicare supplement policy or certificate in force or whether a medicare policy or certificate is intended to replace any other accident and sickness policy or certificate presently in force:

(1) "Do you have another medicare supplement insurance policy or certificate in force, including either a health care service contract or a health maintenance organization contract?";

(2) "Did you have another medicare supplement policy or certificate in force during the last 12 months?" with the following additional questions:

a. "If so, with which company?"and

b. "If that policy lapsed, when did it lapse?";

(3) "Are you covered by Medicaid?"and

(4) "Do you intend to replace any of your medical or health insurance coverage with this policy, certificate?".

(b) A supplementary application or other form signed by the applicant and agent, except where the coverage is sold without an agent, containing the questions outlined in (a) may be used to satisfy the requirements set forth in (a) above.

(c) Agents shall list on the applicant's application form, supplementary application or other form, whichever is used, any other health insurance policies they have sold to the applicant. In addition, the agent shall list those policies sold which are still in force and those policies sold in the past 5 years which are no longer in force.

(d) Upon determining that a sale will involve replacement, an insurer, other than a direct response insurer, or its agent, shall furnish the applicant, prior to issuance or delivery of the medicare supplement policy or certificate, a notice regarding replacement of medicare supplement insurance. One copy of such notice signed by the applicant and the agent, except where the coverage is sold without an agent, shall be provided to the applicant and an additional signed copy shall be retained by the insurer. A direct response insurer shall deliver to the applicant at the time of the issuance of the policy the notice regarding replacement of medicare supplement insurance.

Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5119, eff 4-25-91; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99

New. #8555, eff 2-1-06, EXPIRED: 2-1-14

New. #11014, eff 1-8-16

Ins 1902.09 Loss Ratio Standards and Refund or Credit of Premiums.

(a) A group medicare supplement policy form or certificate form shall not be advertised, solicited, delivered, or issued for delivery unless the policy form or certificate form can be expected, as estimated for the entire period for which rates are computed to provide coverage, on the basis of:

(1) Either:

a. Incurred claims experience; or

b. Incurred health care expenses where coverage is provided by a health maintenance organization on a service rather than reimbursement basis; and

(2) Earned premiums for such period in accordance with accepted actuarial principals and practices, to return to policyholders and certificateholders in the form of aggregate benefits, not including anticipated refunds or credits, provided under the policy form at least 75 percent of the aggregate amount of premiums earned.

(b) An individual medicare supplement policy shall not be advertised, solicited, delivered, or issued for delivery unless the policy form can be expected, as estimated for the entire period for which rates are computed to provide coverage, on the basis of:

(1) Incurred claims experience or incurred health care expenses where coverage is provided by a health maintenance organization on a service rather than reimbursement basis; and

(2) Earned premiums for such period in accordance with accepted actuarial principles and practices, to return to policyholders in the form of aggregate benefits, not including anticipated refunds or credits, provided under the policy form at least 65 percent of the aggregate amount of premiums earned.

(c) The return to policyholders and certificateholders in the form of aggregate benefits of at least 75 percent of the aggregate amount of premiums earned in the case of group policies and of at least 65 percent of the aggregate amount of premiums earned in the case of individual policies shall be deemed the loss ratio standards established by this rule.

(d) All filings of rates and rating schedules shall:

(1) Demonstrate that expected claims in relation to premiums comply with the requirements of this section when combined with actual experience to date; and

(2) Demonstrate if the filing is for a rate revision, that the anticipated loss ratio over the entire future period for which the revised premiums are computed to provide coverage can be expected to meet the appropriate loss ratio standard as determined by reference to Ins 1902.09 (a) in the case of a group policy or to Ins 1902.09 (b) in the case of an individual policy.

(e) For policies issued prior to July 1, 1992, expected claims in relation to premium shall meet:

(1) The originally filed anticipated loss ratio when combined with the actual experience since inception;

(2) The appropriate loss ratio requirement from Ins 1902.09 (a) or Ins 1902.09 (b) when combined with actual experience; and

(3) The appropriate loss ratio requirement from Ins 1902.09 (a) or Ins 1902.09 (b) over the entire future period for which the rates are computed to provide coverage.

(f) Rules applicable to refund or credit calculation reporting shall be as follows:

(1) With respect to Medicare supplement policies or certificates issued prior to July 1, 1992, the issuer shall make one refund or credit calculation combining the experience of all the issuer's individual policies beginning with experience after 12/31/96 and one refund or credit calculation combining the experience of all the issuer's group policies beginning with experience after December 31, 1996;

(2) Each issuer shall collect the data contained in the applicable reporting form contained in Table 1900.03 and, using this reporting form, file the data with the commissioner;

(3) Reports shall be due on May 31 of each year;

(4) If, on the basis of the experience as reported, the benchmark ratio since inception of the reporting requirement, ratio 1 from line 7 of the reporting form contained in Table 1900.03, exceeds the adjusted experience ratio since inception of the same reporting requirement, ratio 3 from line 11 of the reporting form contained in Table 1900.03, then a refund or credit calculation shall be required. The refund calculation shall be done on a statewide basis;

(5) A refund or credit shall be made only when the benchmark loss ratio exceeds the adjusted experience loss ratio and the amount to be refunded or credited exceeds a de minimis level of $5.00 per individual policy or each individual certificate;

(6) The refund shall include interest pursuant to Ins 1905.13 (b)(4) from the end of the calendar year to the date of the refund or credit at a rate specified by the U.S. Secretary of Health and Human Services but in no event shall it be less than the average rate of interest for 13-week Treasury notes; and

(7) A refund or credit against premiums due shall be made by September 30 following the experience year upon which the refund or credit is based.

(g) An issuer of medicare supplement policies and certificates in this state shall file annually its premium rates, rating schedule, and supporting documentation including ratios of incurred to earned premiums by policy duration.

(h) For the purpose of this section, policy forms shall be deemed to comply with the loss ratio standards if:

(1) For the most recent year, the ratio of the incurred losses to earned premiums, for policies or certificates which have been in force for 3 years or more is greater than or equal to the applicable percentages contained in this section;

(2) The expected losses in relation to premiums over the entire period for which the policy is rated comply with the requirements of this section; and

(3) An expected 3rd year loss ratio which is greater than or equal to the applicable percentage shall be demonstrated for policies or certificates in force less than 3 years.

(i) As soon as practicable, but prior to the effective date of enhancements in medicare benefits, every issuer of medicare supplement policies or certificates in this state shall file with the commissioner in accordance with the applicable filing procedures of this state the following items:

(1) Appropriate premium adjustments necessary to produce loss ratios as anticipated for the current premium for the applicable policies or certificates;

(2) Such supporting documents as necessary to justify the premium adjustments; and

(3) Any appropriate riders, endorsements or policy forms needed to accomplish the medicare supplement policy or certificate modification necessary to eliminate benefit duplications with medicare.

(j) An insurer shall make such premium adjustments as are necessary to produce an expected loss ratio under such policy or certificate as will conform with minimum loss ratio standards for medicare supplement policies.

(k) Such premium adjustments shall be expected to result in a loss ratio at least as great as that originally anticipated in the rates used to produce current premiums by the issuer for such medicare policies or certificates.

(l) No premium adjustment which would modify the loss ratio experience under the policy other than the adjustments described herein shall be made with respect to a policy or certificate at any time other than upon its renewal date or anniversary date.

(m) Riders, endorsements, or policy forms filed pursuant to this section shall provide a clear description of the medicare supplement benefits provided by the policy or certificate.

(n) If presented with a request from an issuer for an increase in a rate for a policy or certificate form for which the experience under the form for the previous reporting period is not in compliance with the applicable loss ratio standard, the commissioner, in order to gather information, shall, prior to any approval or disapproval of the request, conduct a public hearing in accordance with RSA 400-A:17 when:

(1) The issuer requests a public hearing, or

(2) At least 10 policyholders or certificate holders request a public hearing.

Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5119, eff 4-25-91; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99

New. #8555, eff 2-1-06, EXPIRED: 2-1-14

New. #11014, eff 1-8-16

Ins 1902.10 Standard for Claims Payment.

(a) An issuer shall comply with section 1882(c)(3) of the Social Security Act, as enacted by section 4081(b)(2)(c) of the Omnibus Budget Reconciliation Act of 1987, OBRA, 1987, Public Law No. 100-203, by:

(1) Accepting a notice from a medicare carrier on dually assigned claims submitted by participating physicians and suppliers as a claim for benefits in place of any other claim form otherwise required and making a payment determination on the basis of the information contained in that notice;

(2) Notifying the participating physicians or supplier and the beneficiary of the payment determination;

(3) Paying the participating physician or supplier directly;

(4) Furnishing, at the time of enrollment, each enrollee with a card listing the policy name, number and a central mailing address to which notices from a medicare carrier may be sent;

(5) Paying user fees for claim notices that are transmitted electronically or otherwise; and

(6) Providing to the Secretary of Health and Human Services, at least annually, a central mailing address to which all claims may be sent by medicare carriers.

Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5119, eff 4-25-91; amd by #5421, eff 7-1-92; ss by #5656, eff 7-1-93; ss by #6405, eff 1-1-97, EXPIRED: 1-1-05

New. #8555, eff 2-1-06, EXPIRED: 2-1-14

New. #11014, eff 1-8-16

Ins 1902.11 Permitted Compensation Arrangements.

(a) An insurer or other entity may provide commission or other compensation to an agent or other representative for the sale of a medicare supplement policy or certificate only if the first year commission or other first year compensation is no more than 200 percent of the commission or other compensation paid for selling or servicing the policy or certificate in the second year or period.

(b) The commission or other compensation provided in subsequent renewal years shall be the same as that provided in the second year or period.

(c) No entity shall provide compensation to its agents or other producers and no agent or producer shall receive compensation greater than the renewal compensation payable by the replacing insurer on renewal policies or certificates if an existing policy or certificate is replaced unless benefits of the new policy or certificate are substantially more favorable than the benefits under the replaced policy.

(d) For purposes of this section, "compensation" shall include pecuniary or nonpecuniary remuneration of any kind relating to the sale or renewal of the policy or certificate, including but not limited to bonuses, gifts, prizes, awards, and finders' fees.

Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5119, eff 4-25-91; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99

New. #8555, eff 2-1-06, EXPIRED: 2-1-14

New. #11014, eff 1-8-16

Ins 1902.12 Appropriations of Recommended Purchase and Excessive Insurance.

(a) In recommending the purchase or replacement of any medicare supplement policy or certificate an agent shall make reasonable efforts to determine the appropriateness of a recommended purchase or replacement.

(b) Any sale of medicare supplement coverage which will provide an individual more than one medicare supplement policy or certificate shall be prohibited; provided, however, that additional medicare supplement coverage may be sold if, when combined with that individual's health coverage already in force, it would insure no more than 100 percent of the individual's actual medical expenses covered under the combined policies.

Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5119, eff 4-25-91; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99

New. #8555, eff 2-1-06, EXPIRED: 2-1-14

New. #11014, eff 1-8-16

Ins 1902.13 Reporting of Multiple Policies.

(a) On or before March 1 of each year, every insurer or other entity providing medicare supplement insurance coverage in this state shall report the following information for every individual resident of this state for which the insurer or entity has in force more than one medicare supplement insurance policy or certificate:

(1) Policy and certificate number; and

(2) Date of issuance.

(b) The items set forth above shall be grouped by individual policyholder.

Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5119, eff 4-25-91; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99

New. #8555, eff 2-1-06, EXPIRED: 2-1-14

New. #11014, eff 1-8-16

Ins 1902.14 Prohibition Against Preexisting Conditions, Waiting Periods, Elimination Periods and Probationary Periods in Replacement Policies or Certificates. If a medicare supplement policy or certificate replaces another medicare supplement policy or certificate, the replacing insurer shall waive any time periods applicable to preexisting conditions, waiting periods, elimination periods, and probationary periods in the new medicare supplement policy for similar benefits to the extent such time was spent under the original policy.

Source. #5119, eff 4-25-91; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99

New. #8555, eff 2-1-06, EXPIRED: 2-1-14

New. #11014, eff 1-8-16

Ins 1902.15 Benefit Conversion Requirements During Transition.

(a) Benefits eliminated by operation of the Medicare Catastrophic Coverage Act of 1988 transition provisions shall be restored.

(b) For medicare supplement policies subject to the minimum standards adopted by the states pursuant to Medicare Catastrophic Coverage Act of 1988, the minimum benefits shall be:

(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 either all or none of the medicare part A inpatient hospital deductible amount;

(3) Coverage of part A medicare eligible expenses incurred as daily hospital charges during use of Medicare’s lifetime hospital inpatient reserve days;

(4) Upon exhaustion of all medicare hospital inpatient coverage including the lifetime reserve days, coverage of 90 percent of all medicare part A eligible expenses for hospitalization not covered by medicare subject to a lifetime maximum benefit for an additional 365 days; and

(5) Coverage under medicare part A for the reasonable cost of the first 3 pints of blood or equivalent quantities of packed red blood cells, as defined under 42 CFR Part 409.87 unless replaced in accordance with 42 CFR Part 409.87 or already paid for under part B.

Source. #5119, eff 4-25-91; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99

New. #8555, eff 2-1-06, EXPIRED: 2-1-14

New. #11014, eff 1-8-16

PART Ins 1903 MEDICARE SUPPLEMENT INSURANCE

Statutory Authority: RSA 400-A:15 II.

Ins 1903.01 Purpose. The purpose of this part is to assure the orderly implementation and conversion of medicare supplement insurance benefits and premiums due to changes in the federal medicare program.

Source. #4553, eff 12-7-88; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99

New. #8556, eff 2-1-06, EXPIRED: 2-1-14

Ins 1903.02 Applicability and Scope.

(a) This part shall take precedence over other rules and requirements relating to medicare supplement policies or contracts only to the extent necessary to assure that benefits are not duplicated, that applicants receive adequate notice and disclosure of changes in medicare supplement policies and contracts, that appropriate premium adjustments are made in a timely manner, and that premiums are reasonable in relation to benefits.

(b) This part shall apply to:

(1) All medicare supplement policies and subscriber contracts advertised, solicited, delivered or issued for delivery in this state, or which are otherwise subject to the jurisdiction of this state and issued prior to July 1, 1992; and

(2) All certificates issued under group medicare supplement policies or subscriber contracts, which policies or contracts have been advertised, solicited, delivered or issued for delivery in this state, or which are otherwise subject to the jurisdiction of this state and issued prior to July 1, 1992.

Source. #8556, eff 2-1-06, EXPIRED: 2-1-14

Ins 1903.03 Definitions.

(a) "Applicant" means:

(1) In the case of an individual medicare supplement policy or subscriber contract, the person who seeks to contract for insurance benefits; and

(2) In the case of group medicare supplement policy or subscriber contract, the proposed certificateholder.

(b) "Certificate" means any certificate issued under a group medicare supplement policy, which policy has been advertised, solicited, delivered, or issued for delivery in this state.

(c) "Insurer" means an insurance company, hospital service corporation, medical service corporation, health service corporation, health maintenance organization or other entity subject to Title XXXVII of the New Hampshire code.

(d) "Medicare supplement policy" means either a group or individual policy of accident and health insurance or a subscriber contract of an insurer that is designed primarily to supplement coverage for hospital, medical or surgical expenses incurred by an insured person which are not covered by medicare. Such term does not include:

(1) 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, or for members or former members, or combination thereof, of the labor organizations; or

(2) A policy or contract of any professional, trade or occupational association for its members or former or retired members, or combination thereof, if such association:

a. Is composed of individuals all of whom are actively engaged in the same profession, trade or occupation;

b. Has been maintained in good faith for purposes other than obtaining insurance; and

c. Has been in existence for at least 2 years prior to the date of its initial offering of such policy or plan to its members.

Source. #8556, eff 2-1-06, EXPIRED: 2-1-14

Ins 1903.04 Benefit Conversion Requirements.

(a) No medicare supplement insurance policy, contract or certificate in force in this state shall contain benefits which duplicate benefits provided by medicare.

(b) No later than 30 days prior to the annual effective date of medicare benefit changes mandated by the Medicare Catastrophic Coverage Act of 1988, every insurer providing medicare supplement insurance or benefits to a resident of this state shall notify its policyholders, contractholders and certificateholders of modifications it has made to medicare supplement insurance policies or contracts.

(c) The notice required in (b) above shall include a description of revisions to the medicare program and a description of each modification made to the coverage provided under the medicare supplement insurance policy or contract. The notice shall inform each covered person as to when any premium adjustment due to changes in medicare benefits will be made. The notice of benefit modifications and any premium adjustments shall be in outline form and in clear and simple terms so as to facilitate comprehension. Such notice shall not contain or be accompanied by any solicitation.

(d) No modifications to an existing medicare supplement contract or policy shall be made at the time of or in connection with the notice requirements of this part except to the extent necessary to eliminate duplication of medicare benefits and any modifications necessary under the policy or contract to provide indexed benefit adjustment.

(e) As soon as practicable, but no longer than 45 days after the effective date of the medicare benefit changes, every insurer providing medicare supplement insurance or contracts in this state shall file with the commissioner, the following:

(1) The appropriate premium adjustments necessary to produce loss ratios as originally anticipated for the applicable policies or contracts. Such supporting documents as necessary to justify the adjustment shall accompany the filing; and

(2) Any appropriate riders, endorsements or policy forms needed to accomplish the medicare supplement insurance modifications necessary to eliminate benefit duplications with medicare. Any such riders, endorsements or policy forms shall provide a clear description of the medicare supplement benefits provided by the policy or contract.

(f) Every insurer providing medicare supplement insurance in this state shall provide each covered person with any rider, endorsement or policy form necessary to eliminate any benefit duplications under the policy or contract with benefits provided by medicare.

(g) No insurer shall require any person covered under a medicare supplement policy or contract which was in force prior to January 1, 1989 to purchase additional coverage under such policy or contract unless additional coverage was provided for in the policy or contract.

(h) Every insurer providing medicare supplement insurance or benefits to a resident of this state shall make such premium adjustments as are necessary to produce an expected loss ratio under such policy or contract as will conform with minimum loss ratio standards for medicare supplement policies and which is expected to result in a loss ratio at least as great as the originally anticipated by the insurer for such medicare supplement insurance policies or contracts. No premium adjustment which would modify the loss ratio experience under the policy other than the adjustments described herein shall be made with respect to a policy at any time other than upon its renewal date. Premium adjustments shall be in the form of refunds or premium credits and shall be made no later than upon renewal if a credit is given, or within 60 days of the renewal date if a refund is provided to premium payer.

Source. #8556, eff 2-1-06, EXPIRED: 2-1-14

Ins 1903.05 Requirements for New Policies and Certificates.

(a) No medicare supplement policy, contract or certificate shall be issued or issued for delivery in this state which provides benefits which duplicate benefits provided by medicare. No such policy, contract or certificate shall provide less benefits than those required under Ins 1902 except where duplication of medicare benefits would result.

(b) Every applicant for a medicare supplement insurance policy or certificate shall be provided with an outline of coverage which simplifies and accurately describes benefits provided by medicare, the benefits provided by the policy or contract being applied for, and the benefit limitations applicable to the policy or contract for which application is being made.

Source. #8556, eff 2-1-06, EXPIRED: 2-1-14

Ins 1903.06 Separability. If any provision of this part or the application thereof to any person or circumstances is for any reason held to be invalid, the remainder of this part and the application of such provision to other persons or circumstances shall not be affected thereby.

Source. #8556, eff 2-1-06, EXPIRED: 2-1-14

PART Ins 1904 GROUP COORDINATION OF BENEFITS

Statutory Authority: RSA 400-A:15 I.; RSA 415-A:2; RSA 420-A:20; RSA 420-B:21

Ins 1904.01 Scope. This part applies to all group or blanket insurance plans subject to RSA 415, RSA 420-A and RSA 420-B.

Source. #3164, eff 12-24-85; ss by #4287, eff 7-1-87; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99

New. #8402, eff 8-1-05; ss by #10371, eff 8-1-13

Ins 1904.02 Purpose. The purpose of this rule is to:

(a) Establish a uniform order of benefit determination under which plans pay claims;

(b) Reduce duplication of benefits by permitting a reduction of the benefits to be paid by plans that, pursuant to rules established by this rule, do not have to pay their benefits first; and

(c) Provide greater efficiency in the processing of claims when a person is covered under more than one plan.

Source. #3164, eff 12-24-85; ss by #4287, eff 7-1-87; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99

New. #8402, eff 8-1-05; ss by #10371, eff 8-1-13

Ins 1904.03 Definitions. As used in this rule, these words and terms have the following meanings, unless the context clearly indicates otherwise:

(a) "Allowable Expense", except as set forth below or where a statute requires a different definition, means:

(1) Any health care expense, including coinsurance or copayments and without reduction for any applicable deductible, that is covered in full or in part by any of the plans covering the person;

(2) If a plan is advised by a covered person that all plans covering the person are high-deductible health plans and the person intends to contribute to a health savings account established in accordance with Section 223 of the Internal Revenue Code of 1986, the primary high-deductible health plan's deductible is not an allowable expense, except for any health care expense incurred that may not be subject to the deductible as described in Section 223(c)(2)(C) of the Internal Revenue Code of 1986;

(3) An expense or a portion of an expense that is not covered by any of the plans is not an allowable expense;

(4) Any expense that a provider by law or in accordance with a contractual agreement is prohibited from charging a covered person is not an allowable expense;

(5) The following are examples of expenses that are not allowable expenses:

a. If a person is confined in a private hospital room, the difference between the cost of a semi-private room in the hospital and the private room is not an allowable expense, unless one of the plans provides coverage for private hospital room expenses;

b. If a person is covered by 2 or more plans that compute their benefit payments on the basis of usual and customary fees or relative value schedule reimbursement or other similar reimbursement methodology, any amount charged by the provider in excess of the highest reimbursement amount for a specified benefit is not an allowable expense;

c. If a person is covered by 2 or more plans that provide benefits or services on the basis of negotiated fees, any amount in excess of the highest of the negotiated fees is not an allowable expense; and

d. If a person is covered by one plan that calculates its benefits or services on the basis of usual and customary fees or relative value schedule reimbursement or other similar reimbursement methodology and another plan that provides its benefits or services on the basis of negotiated fees, the primary plan's payment arrangement shall be the allowable expenses for all plans. However, if the provider has contracted with the secondary plan to provide the benefit or service for a specific negotiated fee or payment amount that is different than the primary plan's payment arrangement and if the provider's contract permits, that negotiated fee or payment shall be the allowable expense used by the secondary plan to determine its benefits;

(6) The definition of "allowable expense" may exclude certain types of coverage or benefits such as dental care, vision care, prescription drug or hearing aids. A plan that limits the application of COB to certain coverages or benefits may limit the definition of allowable expense in its contract to expenses that are similar to the expenses that it provides. When COB is restricted to specific coverages or benefits in a contract, the definition of allowable expense shall include similar expenses to which COB applies;

(7) When a plan provides benefits in the form of services, the reasonable cash value of each service will be considered an allowable expense and a benefit paid;

(8) The amount of the reduction may be excluded from allowable expense when a covered person's benefits are reduced under a primary plan:

a. Because the covered person does not comply with the plan provisions concerning second surgical opinions or precertification of admissions or services; or

b. Because the covered person has a lower benefit because the covered person did not use a preferred provider.

(b) "Birthday" means only the month and day in a calendar year and does not include the year in which the individual is born.

(c) "Claim" means a request that benefits of a plan be provided or paid. The benefits claimed may be in the form of:

(1) Services (including supplies);

(2) Payment for all or a portion of the expenses incurred;

(3) A combination of (1) and (2) above; or

(4) An indemnification.

(d) "Closed panel plan" means a plan that provides health benefits to covered persons primarily in the form of services through a panel of providers that have contracted with or are employed by the plan, and that excludes benefits for services provided by other providers, except in cases of emergency or referral by a panel member.

(e) "Consolidated Omnibus Budget Reconciliation Act of 1985" or "COBRA" means coverage provided under a right of continuation pursuant to federal law.

(f) "Coordination of Benefits" or "COB" means a provision establishing an order in which plans pay their claims, and permitting secondary plans to reduce their benefits so that the combined benefits of all plans do not exceed total allowable expenses.

(g) "Custodial Parent" means:

(1) The parent awarded custody of a child by a court decree; or

(2) In the absence of a court decree, the parent with whom the child resides more than one half of the calendar year without regard to any temporary visitation.

(h) "Group-type Contract" means:

a. A contract that is not available to the general public and is obtained and maintained only because of membership in or a connection with a particular organization or group, including blanket coverage; and

b. "Group-type contract" does not include an individually underwritten and issued guaranteed renewable policy even if the policy is purchased through payroll deduction at a premium savings to the insured since the insured would have the right to maintain or renew the policy independently of continued employment with the employer.

(i) "High-deductible Health Plan" means the meaning given the term under Section 223 of the Internal Revenue Code of 1986, as amended by the Medicare Prescription Drug, Improvement and Modernization Act of 2003.

(j) "Hospital Indemnity Benefits" means:

a. Benefits not related to expenses incurred; and

b. "Hospital indemnity benefits" does not include reimbursement-type benefits even if they are designed or administered to give the insured the right to elect indemnity-type benefits at the time of claim.

(k) "Plan" means:

a. A form of coverage with which coordination is allowed. Separate parts of a plan for members of a group that are provided through alternative contracts that are intended to be part of a coordinated package of benefits are considered one plan and there is not COB among the separate parts of the plan.

b. If a plan coordinates benefits, its contract shall state the types of coverage that will be considered in applying the COB provision of that contract. Whether the contract uses the term "plan" or some other term such as "program", the contractual definition may be no broader than the definition of "plan" in this subsection. The definition of "plan" in the model COB provision in Appendix A is an example.

c. "Plan" includes:

1. Group and nongroup insurance contracts and subscriber contracts;

2. Uninsured arrangements of group or group-type coverage;

3. Group and nongroup coverage through closed panel plans;

4. Group-type contracts;

5. The medical care components of long-term care contracts, such as skilled nursing care;

6. The medical benefits coverage in automobile "no fault" or "personal injury protection" (PIP) type contracts, not including medical payments coverage, also known as Part B in the personal automobile policy or med pay; and

7. Medicare or other governmental benefits, as permitted by law, except as provided in d. 8. below. That part of the definition of plan may be limited to the hospital, medical and surgical benefits of the governmental program; and

d. "Plan" does not include:

1. Hospital indemnity coverage or benefits or other fixed indemnity coverage;

2. Accident only coverage;

3. Specified disease or specified accident coverage;

4. Limited benefits health coverage, as defined in Ins 1901.06 (l);

5. School accident-type coverages that cover students for accidents only, including athletic injuries, either on a 24 hour basis or on a "to and from school" basis;

6. Medical payments coverage in a personal automobile policy, also known as Part B or med pay;

7. Benefits provided in long-term care insurance policies for non-medical services, for example, personal care, adult day care, homemaker services, assistance with activities of daily living, respite care and custodial care or for contracts that pay a fixed daily benefit without regard to expenses incurred or the receipt of services;

8. Medicare supplement policies;

9. A state plan under Medicaid; or

10. A governmental plan, which, by law, provides benefits that are in excess of those of any private insurance plan or other non-governmental plan.

(l) "Policyholder" means the primary insured named in a nongroup insurance policy.

(m) "Primary plan" means a plan whose benefits for a person's health care coverage must be determined without taking the existence of any other plan into consideration. A plan is a primary plan if:

(1) The plan either has no order of benefit determination rules, or its rules differ from those permitted by this rule; or

(2) All plans that cover the person use the order of benefit determination rules required by this rule, and under those rules the plan determines its benefits first.

(n) "Secondary plan" means a plan that is not a primary plan.

Source. #3164, eff 12-24-85; ss by #4287, eff 7-1-87; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99

New. #8402, eff 8-1-05; ss by #10371, eff 8-1-13

Ins 1904.04 Use of Model COB Contract Provision.

(a) Appendix A contains a model COB provision for use in contracts. The use of this model COB provision is subject to the provisions of (b), (c) and (d) below and the provisions of Ins 1904.05.

(b) Appendix B is a plain language description of the COB process that explains to the covered person how health plans will implement coordination of benefits. It is not intended to replace or change the provisions that are set forth in the contract. Its purpose is to explain the process by which the 2 or more plans will pay for or provide benefits.

(c) The COB provision contained in Appendix A and the plain language explanation in Appendix B do not have to use the specific words and format shown in Appendix A or Appendix B. Changes may be made to fit the language and style of the rest of the contract or to reflect differences among plans that provide services, that pay benefits for expenses incurred and that indemnify. No substantive changes are permitted.

(d) A COB provision may not be used that permits a plan to reduce its benefits on the basis that:

(1) Another plan exists and the covered person did not enroll in the plan;

(2) A person is or could have been covered under another plan, except with respect to Part B of Medicare; or

(3) A person has elected an option under another plan providing a lower level of benefits than another option that could have been elected.

(e) No plan may contain a provision that its benefits are "always excess" or "always secondary" except in accordance with the rules permitted by this rule.

(f) Under the terms of a closed panel plan, benefits are not payable if the covered person does not use the services of a closed panel provider. In most instances, COB does not occur if a covered person is enrolled in 2 or more closed panel plans and obtain services from a provider in one of the closed panel plans because the other closed panel plan (the one whose providers were not used) has no liability. However, COB may occur during the plan year when the covered person received emergency services that would have been covered by both plans. Then the secondary plan shall use the provisions of Ins 1904.06 to determine the amount it should pay for the benefit.

(g) No plan may use a COB provision, or any other provision that allows it to reduce its benefits with respect to any other coverage its insured may have that does not meet the definition of plan under Ins 1904.03 (k).

Source. #3164, eff 12-24-85; ss by #4287, eff 7-1-87; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99

New. #8402, eff 8-1-05; ss by #10371, eff 8-1-13

Ins 1904.05 Rules for Coordination of Benefits. When a person is covered by 2 or more plans:

(a) The rules for determining the order of benefit payments are as follows:

(1) The primary plan shall pay or provide its benefits as if the secondary plan or plans did not exist;

(2) If the primary plan is a closed panel plan and the secondary plan is not a closed panel plan, the secondary plan shall pay or provide benefits as if it were the primary plan when a covered person uses a non-panel provider, except for emergency services or authorized referrals that are paid or provided by the primary plan;

(3) When multiple contracts providing coordinated coverage are treated as a single plan under this rule, this section applies only to the plan as a whole, and coordination among the component contracts is governed by the terms of the contracts. If more than one carrier pays or provides benefits under the plan, the carrier designated as primary within the plan shall be responsible for the plan's compliance with this rule; and

(4) If a person is covered by more than one secondary plan, the order of benefit determination rules of this rule decide the order in which secondary plans benefits are determined in relation to each other. Each secondary plan shall take into consideration the benefits of the primary plan or plans and the benefits of any other plan, which, under the rules of this rule, has its benefits determined before those of that secondary plan.

(b) Except as provided in paragraph (2) below:

(1) A plan that does not contain order of benefit determination provisions that are consistent with this rule is always the primary plan unless the provisions of both plans, regardless of the provisions of this paragraph, state that the complying plan is primary; and

(2) Coverage that is obtained by virtue of membership in a group and designed to supplement a part of a basic package of benefits may provide that the supplementary coverage shall be excess to any other parts of the plan provided by the contract holder. Examples of these types of situations are major medical coverages that are superimposed over base plan hospital and surgical benefits, and insurance type coverages that are written in connection with a closed panel plan to provide out-of-network benefits.

(c) A plan may take into consideration the benefits paid or provided by another plan only when, under the rules of this rule, it is secondary to that other plan.

(d) Order of Benefit Determination. Each plan determines its order of benefits using the first of the following rules that applies:

(1) Non-Dependent or Dependent.

a. Subject to subparagraph b. of this paragraph, the plan that covers the person other than as a dependent, for example as an employee, member, subscriber, policyholder or retiree, is the primary plan and the plan that covers the person as a dependent is the secondary plan.

b. If the person is a Medicare beneficiary, and, as a result of the provisions of Title XVIII of the Social Security Act and implementing regulations, Medicare is:

1. Secondary to the plan covering the person as a dependent; and

2. Primary to the plan covering the person as other than a dependent (e.g. a retired employee). Then the order of benefits is reversed so that the plan covering the person as an employee, member, subscriber, policyholder or retiree is the secondary plan and the other plan covering the person as a dependent is the primary plan.

(2) Dependent Child Covered Under More Than One Plan. Unless there is a court decree stating otherwise, plans covering a dependent child shall determine the order of benefits as follows:

a. For a dependent child whose parents are married or are living together, whether or not they have ever been married:

1. The plan of the parent whose birthday falls earlier in the calendar year is the primary plan; or

2. If both parents have the same birthday, the plan that has covered the parent longest is the primary plan.

b. For a dependent child whose parents are divorced or separated or are not living together, whether or not they have ever been married:

1. If a court decree states that one of the parents is responsible for the dependent child's health care expenses or health care coverage and the plan of that parent has actual knowledge of those terms, that plan is primary. If the parent with responsibility has no health care coverage for the dependent child's health care expenses, but that parent's spouse does, that parent's spouse's plan is the primary plan. This item shall not apply with respect to any plan year during which benefits are paid or provided before the entity has actual knowledge of the court decree provision;

2. If a court decree states that both parents are responsible for the dependent child's health care expenses or health care coverage, the provisions of subparagraph a. of this paragraph shall determine the order of benefits;

3. If a court decree states that the parents have joint custody without specifying that one parent has responsibility for the health care expenses or health care coverage of the dependent child, the provisions of subparagraph a. of this paragraph shall determine the order of benefits; or

4. If there is no court decree allocating responsibility for the child's health care expenses or health care coverage, the order of benefits for the child are as follows:

(i) The plan covering the custodial parent;

(ii) The plan covering the custodial parent's spouse;

(iii) The plan covering the non-custodial parent; and then

(iv) The plan covering the non-custodial parent's spouse; and

c. For a dependent child covered under more than one plan of individuals who are not the parents of the child, the order of benefits shall be determined, as applicable, under subparagraph a. or b. of this paragraph as if those individuals were parents of the child.

(3) Active Employee or Retired or Laid-Off Employee.

a. The plan that covers a person as an active employee that is, an employee who is neither laid off nor retired or as a dependent of an active employee is the primary plan. The plan covering that same person as a retired or laid-off employee or as a dependent of a retired or laid-off employee is the secondary plan.

b. If the other plan does not have this rule, and as a result, the plans do not agree on the order of benefits, this rule is ignored; and

c. This rule does not apply if the rule in paragraph (1) can determine the order of benefits.

(4) COBRA or State Continuation Coverage.

a. If a person whose coverage is provided pursuant to COBRA or under a right of continuation pursuant to state or other federal law is covered under another plan, the plan covering the person as an employee, member, subscriber or retiree or covering the person as a dependent of an employee, member, subscriber or retiree is the primary plan and the plan covering that same person pursuant to COBRA or under a right of continuation pursuant to state or other federal law is the secondary plan.

b. If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this rule is ignored; and

c. This rule does not apply if the rule in paragraph (1) can determine the order of benefits.

(5) Longer or Short Length of Coverage.

a. If the preceding rules do not determine the order of benefits, the plan that covered the person for the longer period of time is the primary plan and the plan that covered the person for the shorter period of time is the secondary plan.

b. To determine the length of time a person has been covered under a plan, two successive plans shall be treated as one if the covered person was eligible under the second plan within 24 hours after coverage under the first plan ended.

c. The start of a new plan does not include:

1. A change in the amount or scope of a plan's benefits;

2. A change in the entity that pays, provides or administers the plan's benefits; or

3. A change from one type of plan to another, such as, from a single employer plan to a multiple employer plan; and

d. The person's length of time covered under a plan is measured from the person's first date of coverage under that plan. If that date is not readily available for a group plan, the date the person first became a member of the group shall be used as the date from which to determine the length of time the person's coverage under the present plan has been in force; and

(6) If none of the preceding rules determines the order of benefits, the allowable expenses shall be shared equally between the plans.

Source. #3164, eff 12-24-85; ss by #4287, eff 7-1-87; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99

New. #8402, eff 8-1-05; ss by #10371, eff 8-1-13

Ins 1904.06 Procedure to be Followed by Secondary Plan to Calculate Benefits and Pay a Claim. In determine the amount to be paid by the secondary plan on a claim, should the plan wish to coordinate benefits, the secondary plan shall calculate the benefits it would have paid on the claim in the absence of other health care coverage and apply that calculated amount to any allowable expense under its plan that is unpaid by the primary plan. The secondary plan may reduce its payment by the amount so that, when combined with the amount paid by the primary plan, the total benefits paid or provided by all plans for the claim do not exceed 100 percent of the total allowable expense for that claim. In addition, the secondary plan shall credit to its plan deductible any amounts it would have credited to its deductible in the absence of other health care coverage.

Source. #3164, eff 12-24-85; ss by #4287, eff 7-1-87; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99

New. #8402, eff 8-1-05; ss by #10371, eff 8-1-13

Ins 1904.07 Notice to Covered Persons. A plan shall, in its explanation of benefits provided to covered persons, include the following language; "If you are covered by more than one health benefit plan, you should file all your claims with each plan."

Source. #3164, eff 12-24-85; ss by #4287, eff 7-1-87; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99

New. #8402, eff 8-1-05; ss by #10371, eff 8-1-13

Ins 1904.08 Miscellaneous Provisions.

(a) A secondary plan that provides benefits in the form of services may recover the reasonable cash value of the services from the primary plan, to the extent that benefits for the services are covered by the primary plan and have not already been paid or provided by the primary plan. Nothing in this provision shall be interpreted to require a plan to reimburse a covered person in cash for the value of services provided by a plan that provides benefits in the form of services.

(b) Order of Benefit Determination Rules.

(1) A plan with order of benefit determination rules that comply with this rule (complying plan) may coordinate its benefits with a plan that is "excess" or "always secondary" or that uses order of benefit determination rules that are inconsistent with those contained in this rule (noncomplying plan) on the following basis:

a. If the complying plan is the primary plan, it shall pay or provide its benefits first;

b. If the complying plan is the secondary plan, it shall pay or provide its benefits first, but the amount of the benefits payable shall be determined as if the complying plan were the secondary plan. In such a situation, the payment shall be the limit of the complying plan's liability; and

c. If the noncomplying plan does not provide the information needed by the complying plan to determine its benefits within a reasonable time after it is requested to do so, the complying plan shall assume that the benefits of the noncomplying plan are identical to its own, and shall pay its benefits accordingly. If, within 2 years of payment, the complying plan receives information as to the actual benefits of the noncomplying plan, it shall adjust payments accordingly.

(2) If the noncomplying plan reduces its benefits so that the covered person receives less in benefits than the covered person would have received had the complying plan paid or provided its benefits as the secondary plan and the noncomplying plan paid or provided its benefits as the primary plan, and governing state law allows the right of subrogation set forth below, then the complying plan shall advance to the covered person or on behalf of the covered person an amount equal to the difference; and

(3) In no event shall the complying plan advance more than the complying plan would have paid had it been the primary plan less any amount it previously paid for the same expense or service. In conditions of the advance, the complying plan shall be subrogated to all rights of the covered person against the noncomplying plan. The advance by the complying plan shall also be without prejudice to any claim it may have against a noncomplying plan in the absence of subrogation.

(c) COB differs from subrogation. Provisions for one may be included in health care benefits contracts without compelling the inclusion or exclusion of the other.

(d) If the plans cannot agree on the order of benefits within 30 calendar days after the plans have received all of the information needed to pay the claim, the plans shall immediately pay the claim in equal shares and determine their relative liabilities following payment, except that no plan shall be required to pay more than it would have paid had it been the primary plan.

Source. #3164, eff 12-24-85; ss by #4287, eff 7-1-87; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99

New. #8402, eff 8-1-05; ss by #10371, eff 8-1-13

Ins 1904.09 Effective Date for Existing Contracts.

(a) A contract that provides health care benefits and that was issued before the effective date of this rule shall be brought into compliance with this rule by:

(1) The later of:

a. The next anniversary date or renewal date of the contract; or

b. Twelve months following the effective date of this rule; or

(2) The expiration of any applicable collectively bargained contract pursuant to which it was written.

(b) For the transition period between the adoption of this rule and the timeframe for which plans are to be in compliance pursuant to Subsection A, a plan that is subject to the prior COB requirements shall not be considered a noncomplying plan by a plan subject to the new COB requirements if there is a conflict between the prior COB requirements under the prior rule and the new COB requirements under the amended rule, the prior COB requirements shall apply.

Source. #3164, eff 12-24-85; ss by #4287, eff 7-1-87; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99

New. #8402, eff 8-1-05; ss by #10371, eff 8-1-13

Ins 1904.10 Penalties. Any insurer, producer, or any person, firm, association or corporation violating any provisions of this part shall be subject to the provisions of RSA 400-A:15, III.

Source. #8402, eff 8-1-05; ss by #10371, eff 8-1-13

APPENDIX A

MODEL COB CONTRACT PROVISIONS

COORDINATION OF THIS CONTRACT'S BENEFITS

WITH OTHER BENEFITS

The Coordination of Benefits (COB) provision applies when a person has health care coverage under more than one Plan. Plan is defined below.

The order of benefit determination rules govern the order in which each Plan will pay a claim for benefits. The Plan that pays first is called the Primary plan. The Primary plan must pay benefits in accordance with its policy terms without regard to the possibility that another Plan may cover some expenses. The Plan that pays after the Primary plan is the Secondary plan. The Secondary plan may reduce the benefits it pays so that payments from all Plans does not exceed 100% of the total Allowable expense.

DEFINITIONS

(a) A Plan is any of the following that provides benefits or services for medical or dental care or treatment. If separate contracts are used to provide coordinated coverage for members of a group, the separate contracts are considered parts of the same plan and there is no COB among those separate contracts.

(1) Plan includes: group and nongroup insurance contracts, health maintenance organization (HMO) contracts, closed panel plans or other forms of group or group-type coverage (whether insured or uninsured); medical care components of long-term care contracts, such as skilled nursing care; medical benefits under "no-fault" or "personal injury protection" (PIP) automobile contracts; and Medicare or any other federal governmental plan, as permitted by law.

(2) Plan does not include: hospital indemnity coverage or other fixed indemnity coverage; accident only coverage; specified disease or specified accident coverage; limited benefit health coverage, as defined by state law; school accident type coverage; medical payments coverage in a personal automobile policy, also known as Part B or med pay coverage; benefits for non-medical components of long-term care policies; Medicare supplement policies; Medicaid policies; or coverage under other federal governmental plans, unless permitted by law.

Each contract for coverage under (1) or (2) is a separate Plan. If a Plan has two parts and COB rules apply only to one of the 2, each of the parts is treated as a separate Plan.

(b) This plan means, in a COB provision, the part of the contract providing the health care benefits to which the COB provision applies and which may be reduced because of the benefits to other plans. Any other part of the contract providing health care benefits is separate from this plan. A contract may apply one COB provision to certain benefits, such as dental benefits, coordinating only with similar benefits, and may apply another COB provision to coordinate other benefits.

(c) The order of benefit determination rules determine whether This plan is a Primary plan or Secondary plan when the person has health care coverage under more than one plan.

When This plan is primary, it determines payment for its benefits first before those of any other Plan without considering any other Plan's benefits. When This plan is secondary, it determines its benefits after those of another Plan and may reduce the benefits it pays so that all Plan benefits do not exceed 100% of the total Allowable expense.

(d) Allowable expense is a health care expense, including deductibles, coinsurance and copayments, that is covered at least in part by a Plan covering the person. When a Plan provides benefits in the form of services, the reasonable cash value of each service will be considered an Allowable expense and a benefit paid. An expense that is not covered by any Plan covering the person is not an Allowable expense. In addition, any expense that a provider by law or in accordance with a contractual agreement is prohibited from charging a covered person is not an Allowable expense.

The following are examples of expenses that are not Allowable expenses:

(1) The difference between the cost of a semi-private hospital room and a private hospital room is not an Allowable expense, unless one of the Plans provides coverage for private hospital room expenses.

(2) If a person is covered by 2 or more Plans that compute their benefit payments on the basis of usual and customary fees or relative value schedule reimbursement methodology or other similar reimbursement methodology, any amount in excess of the highest reimbursement amount for a specific benefit is not an Allowable expense.

(3) If a person is covered by 2 or more Plans that provide benefits or services on the basis of negotiated fees, an amount in excess of the highest of the negotiated fees is not an Allowable expense.

(4) If a person is covered by one Plan that calculates its benefits or services on the basis of usual and customary fees or relative value schedule reimbursement methodology or other similar reimbursement methodology and another Plan that provides its benefits or services on the basis of negotiated fees, the Primary plan's payment arrangement shall be the Allowable expense for all Plans. However, if the provider has contracted with the Secondary plan to provide the benefit or service for a specific negotiated fee or payment amount that is different than the Primary plan's payment arrangement and if the provider's contract permits, the negotiated fee or payment shall be the Allowable expense used by the Secondary plan to determine its benefits.

(5) The amount of any benefit reduction by the Primary plan because a covered person has failed to comply with the Plan provisions is not an Allowable expense. Examples of these types of plan provisions include second surgical opinions, precertification of admissions, and preferred provider arrangements.

(e) Closed panel plan is a Plan that provides health care benefits to covered persons primarily in the form of services through a panel or providers that have contracted with or are employed by the Plan, and that excludes coverage for services provided by other providers, except in cases of emergency or referral by a panel member.

(f) Custodial parent is the parent awarded custody by a court decree or, in the absence of a court decree, is the parent with whom the child resides more than one half of the calendar year excluding any temporary visitation.

ORDER OF BENEFIT DETERMINATION RULES

When a person is covered by 2 or more Plans, the rules for determining the order of benefit payments are as follows:

(a) The Primary plan pays or provides its benefits according to its terms of coverage and without regard to the benefits under any other Plan.

(b) Except as provided in paragraph (2),

(1) A Plan that does not contain a coordination of benefits provision that is consistent with this rule is always primary unless the provisions of both Plans state that the complying plan is primary.

(2) Coverage that is obtained by virtue of membership in a group that is designed to supplement a part of a basic package of benefits and provides that this supplementary coverage shall be excess to any other parts of the Plan provided by the contract holder. Examples of these types of situations are major medical coverages that are superimposed over base plan hospital and surgical benefits, and insurance type coverages that are written in connection with a Closed panel plan to provide out-of-network benefits.

(c) A Plan may consider the benefits paid or provided by another Plan in calculating payment of its benefits only when it is secondary to that other Plan.

(d) Each Plan determines its order of benefits using the first of the following rules that apply:

(1) Non-Dependent or Dependent. The Plan that covers the person other than as a dependent, for example as an employee, member, policyholder, subscriber or retiree is the Primary plan and the Plan that covers the person as a dependent is the Secondary plan. However, if the person is a Medicare beneficiary and, as a result of federal law, Medicare is secondary to the Plan covering the person as a dependent; and primary to the Plan covering the person as other than a dependent (e.g. a retired employee); then the order of benefits between the 2 Plans is reversed so that the Plan covering the person as an employee, member, policyholder, subscriber or retiree is the Secondary plan and the other Plan is the Primary plan.

(2) Dependent Child Covered Under More Than One Plan. Unless there is a court decree stating otherwise, when a dependent child is covered by more than one Plan the order of benefits is determined as follows:

a. For a dependent child whose parents are married or are living together, whether or not they have ever been married:

1. The Plan of the parent whose birthday falls earlier in the calendar year is the Primary plan; or

2. If both parents have the same birthday, the Plan that has covered the parent the longest is the Primary plan.

b. For a dependent child whose parents are divorced or separated or not living together, whether or not they have ever been married:

1. If a court decree states that one of the parents is responsible for the dependent child's health care expenses or health care coverage and the Plan of that parent has actual knowledge of those terms, that Plan is primary. This rule applies to plan years commencing after the Plan is given notice of the court decree;

2. If a court decree states that both parents are responsible for the dependent child's health care expenses or health care coverage, the provisions of subparagraph (a) above shall determine the order of benefits;

3. If a court decree states that the parents have joint custody without specifying that one parent has responsibility for the health care expenses or health care coverage of the dependent child, the provisions of subparagraph (a) above shall determine the order of benefits; or

4. If there is no court decree allocating responsibility for the dependent child's health care expenses or health care coverage, the order of benefits for the child are as follows:

The Plan covering the Custodial parent;

The Plan covering the spouse of the Custodial parent;

The Plan covering the non-custodial parent; and then

The Plan covering the spouse of the non-custodial parent.

c. For a dependent child covered under more than one Plan of individuals who are the parents of the child, the provisions of subparagraph (a) or (b) above shall determine the order of benefits as if those individuals were the parents of the child.

(3) Active Employee or Retired or Laid-off Employee. The Plan that covers a person as an active employee, that is, an employee who is neither laid-off nor retired, is the Primary plan. The Plan covering that same person as a retired or laid-off employee is the Secondary plan. The same would hold true if a person is a dependent of an active employee and that same person is a dependent of a retired or laid-off employee. If the other Plan does not have this rule, and as a result, the Plans do not agree on the order of benefits, this rule is ignored. This rule does not apply if the rule labeled (d) (1) can determine the order of benefits.

(4) COBRA or State Continuation Coverage. If a person whose coverage is provided pursuant to COBRA or under a right of continuation provided by state or other federal law is covered under another Plan, the Plan cover the person as an employee, member, subscriber or retiree covering the person as a dependent of an employee, member, subscriber or retiree is the Primary plan and the COBRA or state or other federal continuation coverage is the Secondary plan. If the other Plan does not have this rule, and as a result the Plans do not agree on the order of benefits, this rule is ignored. This rule does not apply if the rule labeled (d)(1) can determine the order of benefits.

(5) Longer or Shorter Length of Coverage. The Plan that covered the person as an employee, member, policyholder, subscriber or retiree longer is the Primary plan and the Plan that covered the person the shorter period of time is the Secondary plan.

(6) If the preceding rules do not determine the order of benefits, the Allowable expenses shall be shared equally between the Plans meeting the definition of Plan. In addition, This plan will not pay more than it would have paid had it been the Primary plan.

EFFECT ON THE BENEFITS OF THIS PLAN

(a) When This plan is secondary, it may reduce its benefits so that the total benefits paid or provided by all Plans during a plan year are not more than the total Allowable expenses. In determining the amount to be paid for any claim, the Secondary plan will calculate the benefits it would have paid in the absence of other health care coverage and apply that calculated amount to any Allowable expense under its Plan that is unpaid by the Primary plan. The Secondary plan may then reduce its payment by the amount so that, when combined with the amount paid by the Primary plan, the total benefits paid or provided by all Plans for the claim do not exceed the total Allowable expense for that claim. In addition, the Secondary plan shall credit to its plan deductible any amounts it would have credited to its deductible in the absence of other health care coverage.

(b) If a covered person is enrolled in two or more Closed panel plans and if, for any reason, including the provision of service by a non-panel provider, benefits are not payable by one Closed panel plan, COB shall not apply between that Plan and other Closed panel plans.

RIGHT TO RECEIVE AND RELEASE NEEDED INFORMATION

Certain facts about health care coverage and services are needed to apply these COB rules and to determine benefits payable under This plan and other Plans. [Organization responsibility for COB administration] may get the facts it needs from or give them to other organizations or persons for the purpose of applying these rules and determining benefits payable under This plan and other Plans covering the person claiming benefits. [Organization responsibility for COB administration] need not tell, or get the consent of, any person to do this. Each person claiming benefits under This plan must give [Organization responsibility for COB administration] any facts it needs to apply those rules and determine benefits payable.

FACILITY OF PAYMENT

A payment made under another Plan may include an amount that should have been paid under This plan. If it does, [Organization responsibility for COB administration] may pay that amount to the organization that made that payment. That amount will then be treated as though it were a benefit paid under This plan. [Organization responsibility for COB administration] will not have to pay that amount again. The term "payment made" includes providing benefits in the form of service, in which case "payment made" means the reasonable cash value of the benefits provided in the form of services.

RIGHT OF RECOVERY

If the amount of the payments made by [Organization responsibility for COB administration] is more than it should have paid under this COB provision, it may recover the excess from one or more of the persons it has paid or for whom it has paid; or any other person or organization that may be responsible for the benefits or services provided for the covered person. The "amount of the payments made" includes the reasonable cash value of any benefits provided in the form of services.

APPENDIX B

CONSUMER EXPLANATORY BOOKLET

COORDINATION OF BENEFITS

IMPORTANT NOTICE

This is a summary of only a few of the provisions of your health plan to help you understand coordination of benefits, which can be very complicated. This is not a complete description of all of the coordination rules and procedures, and does not change or replace the language contained in your insurance contract, which determines your benefits.

Double Coverage

It is common for family members to be covered by more than one health care plan. This happens, for example, when a husband and wife both work and choose to have family coverage through both employers.

When you are covered by more than one health plan, state law permits your insurers to follow a procedure called "coordination of benefits" to determine how much each should pay when you have a claim. The goal is to make sure that the combined payments of all plans do not add up to more than your covered health care expenses.

Coordination of benefits (COB) is complicated, and covers a wide variety of circumstances. This is only an outline of some of the most common ones. If your situation is not described, read your evidence of coverage or contact your state insurance department.

Primary or Secondary?

You will be asked to identify all the plans that cover members of your family. We need this information to determine whether we are the "primary" or "secondary" benefit payer. The primary plan always pays first when you have a claim.

Any plan that does not contain your state's COB rules will always be primary.

When This Plan is Primary

If you or a family member are covered under another plan in addition to this one, we will be primary when:

Your Own Expenses

* The claim is for your own health care expenses, unless you are covered by Medicare and both you and your spouse are retired.

Your Spouse's Expenses

* The claim is for your spouse, who is covered by Medicare, and you are not both retired.

Your Child's Expenses

* The claim is for the health care expenses of your child who is covered by this plan and

* You are married and your birthday is earlier in the year than your spouse's or you are living with another individual, regardless of whether or not you have ever been married to that individual, and your birthday is earlier than that other individual's birthday. This is known as the "birthday rule";

or

* You are separated or divorced and you have informed us of a court decree that makes you responsible for the child's health care expenses;

or

* There is no court decree, but you have custody of the child.

Other Situations

We will be primary when any other provisions of state or federal law require us to be.

How We Pay Claims When We Are Primary

When we are the primary plan, we will pay the benefits in accordance with the terms of your contract, just as if you had no other health care coverage under any other plan.

How We Pay Claims When We Are Secondary

We will be secondary whenever the rules do not require us to be primary.

How We Pay Claims When We Are Secondary

When we are the secondary plan, we do not pay until after the primary plan has paid its benefits. We will then pay part or all of the allowable expenses left unpaid, as explained below. An "allowable expense" is a health care expense covered by one of the plans, including copayments, coinsurance and deductibles.

* If there is a difference between the amount the plans allow, we will base our payment on the higher amount. However, if the primary plan has a contract with the provider, our combined payments will not be more than the amount called for in our contract or the amount called for in the contract of the primary plan, whichever is higher. Health maintenance organizations (HMOs) and preferred provider organizations (PPOs) usually have contracts with their providers.

* We will determine our payment by subtracting the amount the primary plan paid from the amount we would have paid if we had been primary. We may reduce our payment by any amount so that, when combined with the amount paid by the primary plan, the total benefits paid do not exceed the total allowable expense for your claim. We will credit any amount we would have paid in the absence of your other health care coverage toward our own plan deductible.

* If the primary plan covers similar kinds of health care expenses, but allows expenses that we do not cover, we may pay for those expenses.

* We will not pay an amount the primary plan did not cover because you did not follow its rules and procedures. For example, if your plan has reduced its benefits because you did not obtain pre-certification, as required by that plan, we will not pay the amount of the reduction, because it is not an allowable expense.

Questions About Coordination of Benefits?

Contact Your State Insurance Department

Part Ins 1905 Minimum Standards for Medicare Supplement Policies

Statutory Authority: RSA 400-A:15 I; RSA 415-F:3 III - VI; RSA 415-F:5 III - V

Ins 1905.01 Purpose. The purpose of this part 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 accident and sickness insurance coverages to persons eligible for Medicare.

Source. #5390, eff 7-1-92; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99

New. #7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09; ss by #12370, eff 10-13-17

Ins 1905.02 Applicability and Scope.

(a) Except as otherwise specifically provided in Ins 1905.06, Ins 1905.15, Ins 1905.16, Ins 1905.19, and Ins 1905.24, this part shall apply to:

(1) All Medicare supplement policies delivered or issued for delivery in this state on or after the effective date of this part; and

(2) All certificates issued under group Medicare supplement policies, which certificates have been delivered or issued for delivery in this state.

(b) This part shall 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.

Source. #5390, eff 7-1-92; ss by #5656, eff 7-1-93; amd by #6406, eff 1-1-97; ss by #7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09; ss by #12370, eff 10-13-17

Ins 1905.03 Definitions.

(a) “Applicant” means:

(1) In the case of an individual Medicare supplement policy, the person who seeks to contract for insurance benefits; and

(2) In the case of a group Medicare supplement policy, the proposed certificate holder.

(b) “Bankruptcy” means when a Medicare Advantage organization that is not an issuer:

(1) Has filed, or has had filed against it, a petition for declaration of bankruptcy; and

(2) Has ceased doing business in the state.

(c) “Certificate” means any certificate delivered or issued for delivery in this state under a group Medicare supplement policy.

(d) “Certificate form” means the form on which the certificate is delivered or issued for delivery by the issuer.

(e) “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 63 days.

(f) “Creditable coverage” means, with respect to an individual, coverage of the individual provided under any of the following:

(1) A group health plan;

(2) Health insurance coverage;

(3) Part A or Part B of Title XVIII of the Social Security Act (Medicare);

(4) Title XIX of the Social Security Act (Medicaid), other than coverage consisting solely of benefits under section 1928;

(5) Chapter 55 of Title 10 United States Code (CHAMPUS);

(6) A medical care program of the Indian Health Service or of a tribal organization;

(7) A state health benefits risk pool;

(8) A health plan offered under Chapter 89 of Title 5 United States Code (Federal Employees Health Benefits Program;

(9) A public health plan as defined in federal regulation; or

(10) A health benefit plan under 22 United States Code 2504 (e) (Peace Corps Act).

(g) "Creditable coverage" shall not include:

(1) One or more, or any combination of, the following:

a. Coverage only for accident or disability income insurance, or any combination thereof;

b. Coverage issued as a supplement to liability insurance;

c. Liability insurance, including general liability insurance and automobile liability insurance;

d. Workers' compensation or similar insurance;

e. Automobile medical payment insurance;

f. Credit-only insurance;

g. Coverage for on-site medical clinics; and

h. Other similar insurance coverage, specified in federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits;

(2) 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:

a. Limited scope dental or vision benefits;

b. Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; and

c. Such other similar, limited benefits as are specified in federal regulations;

(3) The following benefits if offered as independent, non-coordinated benefits:

a. Coverage only for a specified disease or illness; and

b. Hospital indemnity or other fixed indemnity insurance; and

(4) The following, if it is offered as a separate policy, certificate, or contract of insurance:

a. Medicare supplemental health insurance as defined under section 1882 (g)(1) of the Social Security Act;

b. Coverage supplemental to the coverage provided under chapter 55 of title 10, United States Code; and

c. Similar supplemental coverage provided to coverage under a group health plan.

(h) “Employee welfare benefit plan” means a plan, fund, or program of employee benefits as defined in 29 U.S.C. Chapter 18 Section 1002 (Employee Retirement Income Security Act).

(i) “Insolvency” means when an issuer, licensed to transact the business of insurance in this state, has had a final order of liquidation entered against it with a finding of insolvency by a court of competent jurisdiction in the issuer's state of domicile.

(j) “Issuer” includes insurance companies, fraternal benefit societies, health care service plans, health maintenance organizations, and any other entity delivering or issuing for delivery in this state Medicare supplement policies or certificates.

(k) “Medicare” means the "Health Insurance for the Aged Act," Title XVIII of the Social Security Amendments of 1965, as then constituted or later amended.

(l) “Medicare Advantage plan” means a plan of coverage for health benefits under Medicare Part C as defined in (refer to definition of Medicare Advantage plan in 42 U.S.C. Chapter 7 Section 1395w-28(b)(1)), and includes:

(1) Coordinated care plans that provide health care services, including but not limited to:

a. Health maintenance organization plans, with or without a point-of-service option;

b. Plans offered by provider-sponsored organizations; and

c. Preferred provider organization plans;

(2) Medical savings account plans coupled with a contribution into a Medicare Advantage plan medical savings account; and

(3) Medicare Advantage private fee-for-service plans.

(m) “Medicare supplement policy” means a group or individual policy of accident and sickness insurance or a subscriber contract of hospital and medical service associations or health maintenance organizations, 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. Section 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.

(n) "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 July 1, 1992.

(o) "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 July 1, 1992 and 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.

(p) "2010 Standardized Medicare supplement benefit plan," "2010 Standardized benefit plan", or "2010 plan" means a group or individual policy of Medicare supplement insurance issued on or after June 1, 2010.

(q) “Policy form” means the form on which the policy is delivered or issued for delivery by the issuer.

(r) “Secretary” means the secretary of the United States Department of Health and Human Services.

Source. #5390, eff 7-1-92; ss by #5656, eff 7-1-93; amd by #6406, eff 1-1-97; ss by #7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09; ss by #12370, eff 10-13-17

Ins 1905.04 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 the policy or certificate contains definitions or terms that conform to the requirements of this section as follows:

(a) "Accident”, "accidental injury”, or “accidental means” shall be defined to employ "result" language and shall not include words that establish an accidental means test or use words such as "external, violent, visible wounds" or similar words of description or characterization and shall not be more restrictive than the following:

(1) "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"; and

(2) The definition in (a) above may provide that 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.

(b) “Benefit period” or “Medicare benefit period” shall not be defined more restrictively than as defined in the Medicare program.

(c) “Convalescent nursing home,” “extended care facility,” or “skilled nursing facility” shall not be defined more restrictively than as defined in the Medicare program.

(d) “Health care expenses” means, for purposes of Ins 1905.16, expenses of health maintenance organizations associated with the delivery of health care services, which expenses are analogous to incurred losses of insurers.

(e) “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.

(f) “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.

(g) “Medicare eligible expenses” shall mean expenses of the kinds covered by Medicare Part A and B, to the extent recognized as reasonable and medically necessary by Medicare.

(h) “Physician” shall not be defined more restrictively than as defined in the Medicare program.

(i) “Sickness” shall not be defined to be more restrictive than the following:

(1) "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; and

(2) The definition in (1) above 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.

Source. #5390, eff 7-1-92; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99

New. #7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09; ss by #12370, eff 10-13-17

Ins 1905.05 Policy Provisions.

(a) Except for permitted preexisting condition clauses as described in Ins 1905.06 (b)(1) and (2), Ins 1905.07 (b)(1), and Ins 1905.08 (a)(1) 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.

(b) No Medicare supplement policy or certificate shall use waivers to exclude, limit, or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions.

(c) No Medicare supplement policy or certificate in force in the state shall contain benefits that duplicate benefits provided by Medicare.

(d) Subject to Ins 1905.06 (b)(5), (6), and (8) and Ins 1905.07 (b)(4) and (5), 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.

(e) A Medicare supplement policy with benefits for outpatient prescription drugs shall not be issued after December 31, 2005.

(f) 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:

(1) 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

(2) 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.

Source. #5390, eff 7-1-92; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99

New. #7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09; ss by #12370, eff 10-13-17

Ins 1905.06 Minimum Benefit Standards for Pre-Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery Prior To July 1, 1992.

(a) No policy or certificate shall be advertised, solicited, or issued for delivery in this state as a Medicare supplement policy or certificate unless it meets or exceeds the minimum standards set forth in this section. These are minimum standards and do not preclude the inclusion of other provisions or benefits which are not inconsistent with these standards.

(b) General Standards. The following standards shall apply to Medicare supplement policies and certificates and are in addition to all other requirements of this part:

(1) A Medicare supplement policy or certificate shall not exclude or limit benefits for losses incurred more than 6 months from the effective date of coverage because it involved a preexisting condition;

(2) 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 6 months before the effective date of coverage;

(3) A Medicare supplement policy or certificate shall not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents;

(4) 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, co-payment, or coinsurance amounts. Premiums may be modified to correspond with such changes;

(5) A "noncancellable," "guaranteed renewable," or "noncancellable and guaranteed renewal" Medicare supplement policy shall not:

a. 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

b. Be cancelled or non-renewed by the issuer solely on the grounds of deterioration of health;

(6) Except as authorized by the commissioner 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.

a. If a group Medicare supplement insurance policy is terminated by the group policyholder and not replaced as provided in Ins 1905.06(b)(6)c., the issuer shall offer certificate holders an individual Medicare supplement policy. The issuer shall offer the certificate holder at least the following choices:

1. An individual Medicare supplement policy currently offered by the issuer having comparable benefits to those contained in the terminated group Medicare supplement policy; or

2. An individual Medicare supplement policy which provides only such benefits as are required to meet the minimum standards as defined in Ins 1905.08(b) of this rule;

b. If membership in a group is terminated, the issuer shall:

1. Offer the certificate holder the conversion opportunities described in subparagraph (6)(a); or

2. At the option of the group policyholder, offer the certificate holder continuation of coverage under the group policy; and

c. 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;

(7) 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. Receipt of Medicare Part D benefits will not be considered in determining a continuous loss; and

(8) 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.

(c) Minimum Benefit Standards:

(1) Coverage of Part A Medicare eligible expenses for hospitalization to the extent not covered by Medicare from the 61st day through the 90^th day in any Medicare benefit period;

(2) Coverage for either all or none of the Medicare Part A inpatient hospital deductible amount;

(3) Coverage of Part A Medicare eligible expenses incurred as daily hospital charges during use of Medicare's lifetime hospital inpatient reserve days;

(4) Upon exhaustion of all Medicare hospital inpatient coverage including the lifetime reserve days, coverage of 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;

(5) Coverage under Medicare Part A for the reasonable cost of the first 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 Medicare Part B;

(6) 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 Medicare Part B regardless of hospital confinement, subject to a maximum calendar year out-of-pocket amount equal to the Medicare Part B deductible ($147); and

(7) Effective January 1, 1990, coverage under Medicare Part B for the reasonable cost of the first 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 Medicare Part A, subject to the Medicare deductible amount.

Source. #5390, eff 7-1-92; ss by #5656, eff 7-1-93; amd by #6406, eff 1-1-97; ss by #7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09; ss by #12370, eff 10-13-17

Ins 1905.07 Benefit Standards for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued or Delivered on or after July 1, 1992 and Prior to June 1, 2010.

(a) The standards set forth in this section are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this state on or after July 1, 1992 and 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.

(b) General Standards. The following standards apply to Medicare supplement policies and certificates and are in addition to all other requirements of this rule:

(1) A Medicare supplement policy or certificate shall not exclude or limit benefits for losses incurred more than 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 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 and:

a. The issuer shall not cancel or non-renew the policy solely on the ground of health status of the individual;

b. The issuer shall not cancel or non-renew 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 Ins 1905.07(b)(5)e., the issuer shall offer certificate holders an individual Medicare supplement policy which, at the option of the certificate holder:

1. Provides for continuation of the benefits contained in the group policy, or

2. Provides for benefits that otherwise meet the requirements of this subsection;

d. If an individual is a certificate holder in a group Medicare supplement policy and the individual terminates membership in the group, the issuer shall:

1. Offer the certificate holder the conversion opportunity described in Ins 1905.07(b)(5) c.; or

2. At the option of the group policyholder, offer the certificate holder 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; and

f. 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;

(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 will not be considered in determining a continuous loss;

(7) 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 24 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 90 days after the date the individual becomes entitled to assistance; and

a. 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 90 days after the date of loss and pays the premium attributable to the period, effective as of the date of termination of entitlement;

b. 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 90 days after the date of the loss; and

c. Reinstitution of coverages as described in subparagraphs a. and b. shall:

1. Not provide for any waiting period with respect to treatment of preexisting conditions;

2. 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

3. 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;

(8) 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 Ins 1905.07 of this part, to a 2010 Standardized plan, as described in Ins 1905.08 of this part, the offer and subsequent exchange shall comply with the following requirements:

a. 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 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 shall be filed with the commissioner according to Ins 1905.17;

b. The rating class of the new policy or certificate shall be the class closest to the insured's class of the replaced coverage;

c. An issuer may not apply new preexisting 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 preexisting condition limitations of no more than 6 months to any added benefits contained in the new 2010 Standardized policy or certificate not contained in the exchanged policy; and

d. 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.

(c) Standards for Basic Core Benefits Common to All Benefit Plans A – J. Every issuer shall make available a policy or certificate including only the following basic "core" package of benefits to each prospective insured and 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 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 3 pints of blood, or equivalent quantities of packed red blood cells, as defined under federal regulations, unless replaced in accordance with federal regulations; and

(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.

(d) Standards for Additional Benefits. The following additional benefits shall be included in Medicare supplement benefit plans “B” through “J” only as provided by Ins 1905.09 of this rule:

(1) Medicare Part A deductible shall be coverage for all of the Medicare Part A inpatient hospital deductible amount per benefit period;

(2) Skilled nursing facility care shall be coverage for the actual billed charges up to the coinsurance amount from the 21st day through the 100^th day in a Medicare benefit period for post hospital skilled nursing facility care eligible under Medicare Part A;

(3) Medicare Part B deductible shall be coverage for all of the Medicare Part B deductible amount per calendar year regardless of hospital confinement;

(4) Eighty percent of the Medicare Part B excess charges shall be coverage for 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 of the Medicare Part B excess charges shall be 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 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;

(7) Extended outpatient prescription drug benefit: Coverage for 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;

(8) Medically necessary emergency care in a foreign country: Coverage to the extent not covered by Medicare for 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 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;

(9) Preventive medical care benefit: Coverage for the following preventive health services not covered by Medicare:

a. An annual clinical preventive medical history and physical examination that may include tests and services from subparagraph b., below, and patient education to address preventive health care measures;

b. Preventive screening tests or preventive services, the selection and frequency of which is determined to be medically appropriate by the attending physician; and

c. Reimbursement shall be for the actual charges up to 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; and

(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:

1. “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;

2. “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;

3. “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; and

4. “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:

1. At-home recovery services provided shall be primarily services which assist in activities of daily living;

2. 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;

3. Coverage shall be 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) Sixteen hundred dollars ($1600) 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 (10) a. 2. above;

(vii) At-home recovery visits while the insured is covered under the policy or certificate and not otherwise excluded; and

(viii) At-home recovery visits received during the period the insured is receiving Medicare approved home care services or no more than 8 weeks after the service date of the last Medicare approved home health care visit; and

c. Coverage shall be excluded for:

1. Home care visits paid for by Medicare or other government programs; and

2. Care provided by family members, unpaid volunteers, or providers who are not care providers.

(e) Standards for Plans K and L shall be as follows:

(1) Standardized Medicare supplement benefit plan "K" shall consist of the following:

a. Coverage of 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 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 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 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., below;

e. Skilled Nursing Facility Care: Coverage for 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., below;

f. Hospice Care: Coverage for 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., below;

g. Coverage for 50%, under Medicare Part A or B, of the reasonable cost of the first 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., below;

h. Except for coverage provided in subparagraph i. below, coverage for 50% of the cost sharing otherwise applicable under Medicare Part B after the policyholder pays the Medicare Part B deductible until the out-of-pocket limitation is met as described in subparagraph j., below;

i. Coverage of 100% of the cost sharing for Medicare Part B preventive services after the policyholder pays the Medicare Part B deductible; and

j. Coverage of 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; and

(2) Standardized Medicare supplement benefit plan "L" shall consist of the following:

a. The benefits described in paragraphs (1) a., b., c., and i.;

b. The benefits described in paragraphs (1) d., e., f., g., and h., but substituting 75% for 50%; and

c. The benefit described in paragraph (1) j., but substituting $2000 for $4000.

Source. #5390, eff 7-1-92; ss by #5656, eff 7-1-93; amd by #6406, eff 1-1-97; ss by #7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09; ss by #12370, eff 10-13-17

Ins 1905.08 Benefit Standards for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery 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 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 June 1, 2010. Benefit standards applicable to Medicare supplement policies and certificates issued before June 1, 2010 remain subject to the requirements of Ins 1905.07.

(a) General Standards. The following standards apply to Medicare supplement policies and certificates and are in addition to all other requirements of this part:

(1) A Medicare supplement policy or certificate shall not exclude or limit benefits for losses incurred more than 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 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 and:

a. The issuer shall not cancel or non-renew the policy solely on the ground of health status of the individual;

b. The issuer shall not cancel or non-renew 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 Ins 1905.08(5)(e), the issuer shall offer certificate holders an individual Medicare supplement policy which, at the option of the certificate holder:

1. Provides for continuation of the benefits contained in the group policy; or

2. Provides for benefits that otherwise meet the requirements of this subsection;

d. If an individual is a certificate holder in a group Medicare supplement policy and the individual terminates membership in the group, the issuer shall:

1. Offer the certificate holder the conversion opportunity described in Ins 1905.08(a)(5)c.; or

2. At the option of the group policyholder, offer the certificate holder continuation of coverage under the group policy; and

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 will 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 certificate holder for the period, not to exceed 24 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 90 days after the date the individual becomes entitled to assistance;

b. 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 90 days after the date of loss and pays the premium attributable to the period, effective as of the date of termination of entitlement;

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 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 90 days after the date of loss; and

d. Reinstitution of coverages as described in subparagraphs b. and c above:

1. Shall not provide for any waiting period with respect to treatment of preexisting conditions;

2. Shall provide for resumption of coverage that is substantially equivalent to coverage in effect before the date of suspension; and

3. 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.

(b) Standards for Basic Core Benefits Common to Medicare Supplement Insurance Benefit Plans A, B, C, D, E, 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 and 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 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 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 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 Medicare Part B regardless of hospital confinement, subject to the Medicare Part B deductible; and

(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, E, F, F with High Deductible, G, M and N as provided by Ins 1905.10:

(1) Medicare Part A Deductible: Coverage for 100% of the Medicare Part A inpatient hospital deductible amount per benefit period;

(2) Medicare Part A Deductible: Coverage for 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 100% 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; and

(6) Medically Necessary Emergency Care in a Foreign Country: Coverage to the extent not covered by Medicare for 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 60 consecutive days of each trip outside the United States, subject to 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.

Source. #5390, eff 7-1-92; ss by #5656, eff 7-1-93; ss by #6406, eff 1-1-97; ss by #7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09; ss by #12370, eff 10-13-17

Ins 1905.09 Standard Medicare Supplement Benefit Plans for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or After July 1, 1992 and Prior to June 1, 2010.

(a) 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 Ins 1905.07(c) of this rule.

(b) No groups, packages or combinations of Medicare supplement benefits other than those listed in this section shall be offered for sale in this state, except as may be permitted in Ins 1905.09(f) and Ins 1905.12.

(c) Benefit plans shall be uniform in structure, language, designation, and format to the standard benefit plans "A" through "L" listed in this subsection and conform to the definitions in Ins 1905.03. Each benefit shall be structured in accordance with the format provided in Ins 1905.07(c), (d), and (e) and list the benefits in the order shown in this subsection. For purposes of this section, "structure, language, and format" means style, arrangement and overall content of a benefit.

(d) An issuer may use, in addition to the benefit plan designations required in paragraph (c) above, other designations to the extent permitted by law.

(e) Make-up of benefit plans:

(1) Standardized Medicare supplement benefit plan "A" shall be limited to the basic core benefits common to all benefit plans, as defined in Ins 1905.07(c);

(2) Standardized Medicare supplement benefit plan "B" shall include only the following:

a. The core benefit as specified in Ins 1905.07(c) of this rule; plus

b. The Medicare Part A deductible as defined in Ins 1905.07(d)(1);

(3) Standardized Medicare supplement benefit plan "C" shall include only the following:

a. The core benefit as defined in Ins 1905.07(c); plus

b. The Medicare Part A deductible as defined in Ins 1905.07(d)(1);

c. Skilled nursing facility care as defined in Ins 1905.07(d)(2);

d. Medicare Part B deductible as defined in Ins 1905.07(d)(3); and

e. Medically necessary emergency care in a foreign country as defined in Ins 1905.07(d)(8);

(4) Standardized Medicare supplement benefit plan "D" shall include only the following:

a. The core benefit as defined in Ins 1905.07(c) of this rule; plus

b. The Medicare Part A deductible as defined in Ins 1905.07(d)(1);

c. Skilled nursing facility care as defined in Ins 1905.07(d)(2);

d. Medically necessary emergency care in a foreign country as defined in Ins 1905.07(d)(8); and

e. The at-home recovery benefit as defined in Ins 1905.07(d)(10);

(5) Standardized Medicare supplement benefit plan "E" shall include only the following:

a. The core benefit as defined in Ins 1905.07(c) of this rule; plus

b. The Medicare Part A deductible as defined in Ins 1905.07(d)(1);

c. Skilled nursing facility care as defined in Ins 1905.07(d)(2);

d. Medically necessary emergency care in a foreign country as defined in Ins 1905.07 (d)(8); and

e. Preventive medical care as defined in Ins 1905.07(d)(9);

(6) Standardized Medicare supplement benefit plan "F" shall include only the following:

a. The core benefit as defined in Ins 1905.07(c) of this rule; plus

b. The Medicare Part A deductible as defined in Ins 1905.07(d)(1);

c. The skilled nursing facility care as defined in Ins 1905.07(d)(2);

d. The Part B deductible as defined in Ins 1905.07(d)(3);

e. One hundred percent of the Medicare Part B excess charges as defined in Ins 1905.07(d)(5); and

f. Medically necessary emergency care in a foreign country as defined in Ins 1905.07(d)(8);

(7) Standardized Medicare supplement benefit high deductible plan "F" shall include only the following:

a. 100% of covered expenses following the payment of the annual high deductible plan F deductible. The covered expenses include:

1. The core benefit as defined in Ins 1905.07(c) of this rule; plus

2. The Medicare Part A deductible as defined in Ins 1905.07(d)(1);

3. Skilled nursing facility care as defined in Ins 1905.07(d)(2);

4. The Medicare Part B deductible as defined in Ins 1905.07(d)(3);

5. One hundred percent of the Medicare Part B excess charges as defined in Ins 1905.07(d)(5); and

6. Medically necessary emergency care in a foreign country as defined in Ins 1905.07(d)(8);

b. 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;

c. The annual high deductible plan "F" deductible shall be $1500 for 1998 and 1999, and shall be based on the calendar year; and

d. It shall be adjusted annually thereafter by the Secretary to reflect the change in the consumer price index for all urban consumers for the 12 month period ending with August of the preceding year, and rounded to the nearest multiple of $10;

(8) Standardized Medicare supplement benefit plan "G" shall include only the following:

a. The core benefit as defined in Ins 1905.07(c) of this rule; plus

b. The Medicare Part A deductible as defined in Ins 1905.07(d)(1);

c. Skilled nursing facility care as defined in Ins 1905.07(d)(2);

d. Eighty percent of the Medicare Part B excess charges as defined in Ins 1905.07(d)(4);

e. Medically necessary emergency care in a foreign country as defined in Ins 1905.07(d)(8); and

f. The at-home recovery benefit as defined in Ins 1905.07(d)(10);

(9) Standardized Medicare supplement benefit plan "H" shall consist of only the following:

a. The core benefit as defined in Ins 1905.07(c) of this rule; plus

b. The Medicare Part A deductible as defined in Ins 1905.07(d)(1);

c. Skilled nursing facility care as defined in Ins 1905.07(d)(2);

d. Basic prescription drug benefit as defined in Ins 1905.07(d)(6); and

e. Medically necessary emergency care in a foreign country as defined in Ins 1905.07(d)(8); and

f. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005;

(10) Standardized Medicare supplement benefit plan "I" shall consist of only the following:

a. The core benefit as defined in Ins 1905.07(c) of this rule; plus

b. The Medicare Part A deductible as defined in Ins 1905.07(d)(1);

c. Skilled nursing facility care as defined in Ins 1905.07(d)(2);

d. One hundred percent of the Medicare Part B excess charges as defined in Ins 1905.07(d)(5);

e. Basic prescription drug benefit as defined in Ins 1905.07(d)(6);

f. Medically necessary emergency care in a foreign country as defined in Ins 1905.07(d)(8);

g. At-home recovery benefits as defined in Ins 1905.07 (d)(10); and

h. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005;

(11) Standardized Medicare supplement benefit plan "J" shall consist of only the following:

a. The core benefit as defined in Ins 1905.07(c) of this rule; plus

b. The Medicare Part A deductible as defined in Ins 1905.07(d)(1);

c. Skilled nursing facility care as defined in Ins 1905.07(d)(2);

d. Medicare Part B deductible as defined in Ins 1905.07(d)(3);

e. One hundred percent of the Medicare Part B excess charges as defined in Ins 1905.07(d)(5);

f. Extended prescription drug benefit as defined in Ins 1905.07(d)(7);

g. Medically necessary emergency care in a foreign country as defined in Ins 1905.07(d)(8);

h. Preventive medical care as defined in Ins 1905.07(d)(9);

i. At-home recovery benefit as defined in Ins 1905.07(d)(10); and

j. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005;

(12) Standardized Medicare supplement benefit high deductible plan "J" shall consist of only the following:

a. One hundred percent of covered expenses, following the payment of the annual high deductible plan “J” deductible. The covered expenses include:

1. The core benefit as defined in Ins 1905.07(c) of this rule; plus

2. The Medicare Part A deductible as defined in Ins 1905.07(d)(1);

3. Skilled nursing facility care as defined in Ins 1905.07(d)(2);

4. Medicare Part B deductible as defined in Ins 1905.07(d)(3);

5. One hundred percent of the Medicare Part B excess charges as defined in Ins 1905.07(d)(5);

6. Extended outpatient prescription drug benefit as defined in Ins 1905.07(d)(7);

7. Medically necessary emergency care in a foreign country as defined in Ins 1905.07(d)(8);

8. Preventive medical care benefit as defined in Ins 1905.07(d)(9); and

9. At-home recovery benefit as defined in Ins 1905.07(d)(10);

b. 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;

c. The annual deductible shall be $1500 for 1998 and 1999, and shall be based on a calendar year;

d. It shall be adjusted annually thereafter by the Secretary to reflect the change in the consumer price index for all urban consumers for the 12 month period ending with August of the preceding year, and rounded to the nearest multiple of $10; and

e. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005; and

(13) 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 Ins 1905.07(e)(1); and

b. Standardized Medicare supplement benefit plan "L" shall consist of only those benefits described in Ins 1905.07(e)(2).

(f) New or Innovative Benefits. An issuer may, with the prior approval of the commissioner, 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.

Source. #5390, eff 7-1-92; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99

New. #7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09; ss by #12370, eff 10-13-17

Ins 1905.10 Standard Medicare Supplement Benefit Plans for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery 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 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 before June 1, 2010 remain subject to the requirements of Ins 1905.07:

(a) (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 Ins 1905.08(b).

(2) If an issuer makes available any of the additional benefits described in Ins 1905.08(c) or offers standardized benefit plans “K” or “L”, as described in Ins 1905.10(e)(8) and (9), 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 Ins 1905.10(a)(1) above, a policy form or certificate form containing either standardized benefit plan “C”, as described in Ins 1905.10(e)(3) or standardized benefit plan “F”, as described in Ins 1905.10(e)(5).

(b) No groups, packages, or combinations of Medicare supplement benefits other than those listed in this section shall be offered for sale in this state, except as may be permitted in Ins 1905.10 (f) and Ins 1905.12.

(c) Benefit plans shall be uniform in structure, language, designation, and format to the standard benefit plans listed in this subsection and conform to the definitions in Ins 1905.03. Each benefit shall be structured in accordance with the format provided in Ins 1905.08(b); or, in the case of plans “K” or “L”, in Ins 1905.10(e)(8) or (9) and list the benefits in the order shown. For purposes of this section, "structure, language, and format" means style, arrangement, and overall content of a benefit.

(d) In addition to the benefit plan designations required in Ins 1905.10(c), an issuer may use other designations to the extent permitted by law.

(e) Make-up of 2010 Standardized Benefit Plans:

(1) Standardized Medicare supplement benefit plan “A” shall include only the following:

a. The basic core benefits as defined in Ins 1905.08(b);

(2) Standardized Medicare supplement benefit plan “B” shall include only the following:

a. The basic core benefit as defined in Ins 1905.08(b); plus

b. One hundred percent of the Medicare Part A deductible as defined in Ins 1905.08(c)(1);

(3) Standardized Medicare supplement benefit plan “C” shall include only the following:

a. The basic core benefit as defined in Ins 1905.08(b); plus

b. One hundred percent of the Medicare Part A deductible as defined in Ins 1905.08(c)(1);

c. Skilled nursing facility care as defined in Ins 1905.08(c)(3);

d. One hundred percent of the Medicare Part B deductible as defined in Ins 1905.08(c)(4); and

e. Medically necessary emergency care in a foreign country as defined in Ins 1905.08(c)(6);

(4) Standardized Medicare supplement benefit plan “D” shall include only the following:

a. The basic core benefit as defined in Ins 1905.08(b); plus

b. One hundred percent of the Medicare Part A deductible as defined in Ins 1905.08(c)(1);

c. Skilled nursing facility care as defined in Ins 1905.08(c)(3); and

d. Medically necessary emergency care in a foreign country as defined in Ins 1905.08(c)(6);

(5) Standardized Medicare supplement (regular) plan “F” shall include only the following:

a. The basic core benefit as defined in Ins 1905.08(b); plus

b. One hundred percent of the Medicare Part A deductible as defined in Ins 1905.08(c)(1);

c. The skilled nursing facility care as defined in Ins 1905.08(c)(3);

d. One hundred percent of the Medicare Part B deductible as defined in Ins 1905.08(c)(4);

e. One hundred percent of the Medicare Part B excess charges as defined in Ins 1905.08(c)(5); and

f. Medically necessary care in a foreign country as defined in Ins 1905.08(c)(6);

(6) Standardized Medicare supplement plan “F” with high deductible shall include only the following:

a. One hundred percent of covered expenses following the payment of the annual deductible set forth in subparagraph h;

b. The basic core benefit as defined in Ins 1905.08(b); plus

c. One hundred percent of the Medicare Part A deductible as defined in Ins 1905.08(c)(1);

d. Skilled nursing facility care as defined in Ins 1905.08(c)(3);

e. One hundred percent of the Medicare Part B deductible as defined in Ins 1905.08(c)(4);

f. One hundred percent of the Medicare Part B excess charges as defined in Ins 2905.08(c)(5);

g. Medically necessary emergency care in a foreign country as defined in Ins 1905.08(c)(6); and

h. 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 $1,500 and shall be adjusted annually from 1999 by the Secretary of the U.S. Department of Health and Human Services to reflect the change in the consumer price index for all urban consumers for the 12 month period ending with August of the preceding year, and rounded to the nearest multiple of 10 dollars;

(7) Standardized Medicare supplement benefit plan “G” shall include only the following:

a. The basic core benefit as defined in Ins 1905.08(b); plus

b. One hundred percent of the Medicare Part A deductible as defined in Ins 1905.08(c)(1);

c. Skilled nursing facility care as defined in Ins 1905.08(c)(3);

d. One hundred percent of the Medicare Part B excess charges as defined in Ins 1905.08(c)(5);

e. Medically necessary emergency care in a foreign country as defined in Ins 1905.08(c)(6); and

f. Effective January 1, 2020, the standardized benefit plans describe in Ins 1905.11(a)(4) – redesignated Plan G High Deductible – may be offered to any individual who was eligible for Medicare prior to January 1, 2020.

(8) Standardized Medicare supplement plan “K” is mandated by The Medicare Prescription Drug, Improvement and Modernization Act of 2003, and shall include only the following:

a. Part A Hospital Coinsurance, 61st through 90th days: Coverage of 100% of the Part A hospital coinsurance amount for each day from the 61st through the 90th day in any Medicare benefit period;

b. Part A Hospital Coinsurance, 91st through 150th days: Coverage of 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. Part A Hospitalization After 150 Days: Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 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 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., below;

e. Skilled Nursing Facility Care: Coverage for 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., below;

f. Hospice Care: Coverage for 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., below;

g. Blood: Coverage for 50%, under Medicare Part A or B, of the reasonable cost of the first 3 pints of blood, or equivalent quantities of packed red blood cells, and defined under federal regulations, unless replaced in accordance with federal regulations until the out-of-pocket limitation is met as described in subparagraph j., below;

h. Part B Cost Sharing: Except for coverage provided in subparagraph i, coverage for 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., below;

i. Part B Preventive Services: Coverage of 100% of the cost sharing for Medicare Part B preventive services after the policyholder pays the Part B deductible; and

j. Cost Sharing After Out-of-Pocket Limits: Coverage of 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 $4,000 in 2006, indexed each year by the appropriate inflation adjustment specified by the Secretary of the U.S. Department of Health and Human Services;

(9) Standardized Medicare supplement plan “L” is mandated by The Medicare Prescription Drug, Improvement and Modernization Act of 2003, and shall include only the following:

a. The benefits described in Ins 1905.10(e)(8)a., b., c., and i.;

b. The benefits described in Ins 1905.10(e)(8)d., e., f., g., and h., but substituting 75% for 50%; and

c. The benefits described in Ins 1905.10(e)(8)j., but substituting $2,000 for $4,000;

(10) Standardized Medicare supplement plan “M” shall include only the following:

a. The basic core benefit as defined in Ins 1905.08(b); plus

b. Fifty percent of the Medicare Part A deductible as defined in Ins 1905.08(c)(2);

c. Skilled nursing facility care as defined in Ins 1905.08(c)(3); and

d. Medically necessary emergency care in a foreign country as defined in Ins 1905.08(c)(6); and

(11) Standardized Medicare supplement plan “N” shall include only the following:

a. The basic core benefit as defined in Ins 1905.08(b); plus

b. One hundred percent of the Medicare Part A deductible as defined in Ins 1905.08(c)(1);

c. Skilled nursing facility care as defined in Ins 1905.08(c)(3); and

d. Medically necessary emergency care in a foreign country as defined in Ins 1905.08(c)(6), with co-payments in the following amounts:

1. The lesser of $20 or the Medicare Part B coinsurance or copayment for each covered health care provider office visit, including visits to medical specialists; and

2. The lesser of $50 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.

(f) New or Innovative Benefits: An insurer may, with the prior approval of the commissioner, 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 shall 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.

Source. #5390, eff 7-1-92; ss by #5656, eff 7-1-93; amd by #6406, eff 1-1-97; ss by #7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09; ss by #12370, eff 10-13-17

Ins 1905.11 Standard Medicare Supplement Benefit Plans for 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 that 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 Ins 1905.10:

(a) Benefit Requirements. The standards and requirements of Section Ins 1905.10 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:

(1) Standardized Medicare supplement benefit Plan C is redesignated as Plan D and shall provide the benefits contained in Ins 1905.10(e)(3) but shall not provide coverage for one hundred percent (100%) or any portion of the Medicare Part B deductible;

(2) Standardized Medicare supplement benefit Plan F is redesignated as Plan G and shall provide the benefits contained in Ins 1905.10(e)(5) but shall not provide coverage for one hundred percent (100%) or any portion of the Medicare Part B deductible;

(3) 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;

(4) Standardized Medicare supplement benefit Plan F With High Deductible is redesignated as Plan G With High Deductible and shall provide the benefits contained in Ins 1905.10(e)(6) but shall not provide coverage for one hundred percent (100%) 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; and

(5) The reference to Plans C or F contained in Ins 1905.10(a)(2) is deemed a reference to Plans D or G for purposes of this section.

(b) Applicability to Certain Individuals. Ins 1905.11 applies to only individuals that are newly eligible for Medicare on or after January 1, 2020:

(1) By reason of attaining age 65 on or after January 1, 2020; or

(2) By reason of entitlement to benefits under part A pursuant to Section 226(b) or 226A of the Social Security Act, available as referenced in Appendix A, or who is deemed to be eligible for benefits under Section 226(a) of the Social Security Act on or after January 1, 2020.

(c) Guaranteed Issue for Eligible Persons. For purposes of Ins 1905.14(e), 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 Ins 1905.11(a).

(d) Applicability to Waivered States. In the case of a state described in Section 1882(p)(6) of the Social Security Act (“waivered” alternative simplification states), MACRA prohibits the coverage of the Medicare Part B deductible for any Medicare supplement policy sold or issued to an individual that is newly eligible for Medicare on or after January 1, 2020.

(e) Offer of Redesignated Plans to Individuals Other Than Newly Eligible. On or after January 1, 2020, the standardized benefit plans described in subparagraph Ins 1905.11(a)(4), above, may be offered to any individual who was eligible for Medicare prior to January 1, 2020, in addition to the standardized plans described in Ins 1905.10(e).

Source. #12370, eff 10-13-17

Ins 1905.12 Medicare Select Policies and Certificates.

(a) This section shall apply to Medicare Select policies and certificates, as defined in this section.

(b) No policy or certificate may be advertised as a Medicare Select policy or certificate unless it meets the requirements of this section.

(c) For the purposes of this section:

(1) "Complaint" means any dissatisfaction expressed by an individual concerning a Medicare Select issuer or its network providers;

(2) "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;

(3) "Medicare Select issuer" means an issuer offering, or seeking to offer, a Medicare Select policy or certificate;

(4) "Medicare Select policy" or "Medicare Select certificate" means respectively a Medicare supplement policy or certificate that contains restricted network provisions;

(5) "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;

(6) "Restricted network provision" means any provision which conditions the payment of benefits, in whole or in part, on the use of network providers; and

(7) "Service area" means the geographic area approved by the commissioner within which an issuer is authorized to offer a Medicare Select policy.

(d) The commissioner may authorize an issuer to offer a Medicare Select policy or certificate, pursuant to this section and Section 4358 of the Omnibus Budget Reconciliation Act (OBRA) of 1990 if the commissioner finds that the issuer has satisfied all of the requirements of this rule.

(e) 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 commissioner.

(f) A Medicare Select issuer shall file a proposed plan of operation with the commissioner in a format prescribed by the commissioner. The plan of operation shall contain at least the following information:

(1) Evidence that all covered services that are subject to restricted network provisions are available and accessible through network providers, including a demonstration that:

a. 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;

b. The number of network providers in the service area is sufficient, with respect to current and expected policyholders, either:

1. To deliver adequately all services that are subject to a restricted network provision; or

2. To make appropriate referrals;

c. There are written agreements with network providers describing specific responsibilities;

d. Emergency care is available 24 hours per day and 7 days per week; and

e. 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;

(2) A statement or map providing a clear description of the service area;

(3) A description of the grievance procedure to be utilized;

(4) A description of the quality assurance program, including:

a. The formal organizational structure;

b. The written criteria for selection, retention and removal of network providers; and

c. The procedures for evaluating quality of care provided by network providers, and the process to initiate corrective action when warranted;

(5) A list and description, by specialty, of the network providers;

(6) Copies of the written information proposed to be used by the issuer to comply with paragraph (k) below; and

(7) Any other information requested by the commissioner.

(g) 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 commissioner prior to implementing the changes. Changes shall be considered approved by the commissioner after 30 days unless specifically disapproved.

(h) An updated list of network providers shall be filed with the commissioner at least quarterly.

(i) A Medicare Select policy or certificate shall not restrict payment for covered services provided by non-network providers if:

(1) The services are for symptoms requiring emergency care or are immediately required for an unforeseen illness, injury or a condition; and

(2) It is not reasonable to obtain services through a network provider.

(j) 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.

(k) 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:

(1) An outline of coverage sufficient to permit the applicant to compare the coverage and premiums of the Medicare Select policy or certificate with:

a. Other Medicare supplement policies or certificates offered by the issuer; and

b. Other Medicare Select policies or certificates;

(2) A description, including address, phone number and hours of operation, of the network providers, including primary care physicians, specialty physicians, hospitals and other providers;

(3) 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”;

(4) A description of coverage for emergency and urgently needed care and other out-of-service area coverage;