(1) Medicare supplement policies and certificates must include a renewal or continuation provision. The language or specifications of the provision must be consistent with the type of contract to be issued. The provision must be appropriately captioned, must appear on the first page of the policy, and must include any reservation by the issuer of the right to change premiums and any automatic renewal premium increases based on the policyholder’s age.
(2) Except for riders or endorsements by which the issuer effectuates a request made in writing by the insured or 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 must require a signed acceptance by the insured. After the date of policy or certificate issue, any rider or endorsement that increases benefits or coverage with a concomitant increase in premium during the policy term must be agreed to in writing and signed by the insured, unless the increased benefits or coverage are required by the minimum standards for Medicare supplement policies, or if the increased benefits or coverage is required by law. If a separate additional premium is charged for benefits provided in connection with riders or endorsements, the premium charge must be set forth in the policy.
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(3) Medicare supplement policies or certificates must not provide for the payment of benefits based on standards described as “usual and customary,” “reasonable and customary,” or words of similar import.
(4) If a Medicare supplement policy or certificate contains any limitations with respect to preexisting conditions, the limitations must appear as a separate paragraph of the policy and be labeled as “Preexisting Condition Limitations”.
(5) Medicare supplement policies and certificates must have notices prominently printed on the first page of the policy or certificate or attached thereto stating in substance 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.
(6) Issuers of accident and sickness policies or certificates or subscriber contracts that provide hospital or medical expense coverage on an expense incurred or indemnity basis to persons eligible for Medicare must provide to such applicants a Medicare supplement “buyer’s guide”. This may be the pamphlet entitled “Guide to Health Insurance for People with Medicare,” developed jointly by the national association of insurance commissioners and the center for Medicaid and Medicare services (CMS) of the U.S. Department of Health and Human Services, or any reproduction or official revision of that pamphlet in a type size no smaller than 12 point type. The “buyer’s guide” must conform to the language, format, type size, type proportional spacing, bold character, and line spaces as specified in Appendix C of the NAIC Model Regulation (see ARM 6.6.526).
(a) Delivery of the “buyer’s guide” must be made whether or not such policies or certificates are advertised, solicited, or issued as Medicare supplement policies or certificates as defined in this rule. Except in the case of direct response issuers, delivery of the “buyer’s guide” must be made to the applicant at the time of application and acknowledgment of receipt of the “buyer’s guide” must be obtained by the issuer. Direct response issuers must deliver the “buyer’s guide” to the applicant upon request but not later than at the time the policy is delivered.
(7) As soon as practicable, but no later than 30 days prior to the annual effective date of any Medicare benefit changes, an issuer shall notify its policyholders and certificateholders of modifications it has made to Medicare supplement insurance policies or certificates in a format acceptable to the commissioner. Such notice must:
(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 policy or certificate; and
(b) inform each policyholder or certificateholder as to when any premium adjustment is to be made due to changes in Medicare;
(c) The notice of benefit modifications and any premium adjustments shall be in outline form and in clear and concise terms so as to facilitate comprehension; and
(d) Such notices must not contain, or be accompanied by, any solicitation.
(8) Issuers shall comply with any notice requirements of the MMA.
(9) Issuers shall provide an outline of coverage to each applicant at the time application is presented to the prospective applicant and, except for direct response policies, shall obtain an acknowledgment of receipt of such outline from the applicant:
(a) 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 must accompany such policy or certificate when it is delivered and contain the following statement, in no less than 12 point bold type, immediately above the company name:
“NOTICE: Read this outline of coverage carefully. It is not identical to the outline of coverage provided upon application and the coverage originally applied for has not been issued.”
(b) The outline of coverage provided to applicants consists of a cover page, premium information, disclosure pages, and charts displaying the features of each benefit plan offered by the issuer. The outline of coverage must be in the language and format prescribed below in no less than 12 point type. All plans must be shown on the cover page, and the plans that are offered by the issuer must be prominently identified. Premium information for plans that are offered must be shown on the cover page or immediately following the cover page and must be prominently displayed. The premium and mode shall be stated for all plans that are offered to the prospective applicant. All possible premiums for the prospective applicant must be illustrated.
(c) The following items must be included in the outline of coverage in the order prescribed below:
[COMPANY NAME]Outline of Medicare Supplement Coverage-Cover Page: 1 of 2Benefit Plan(s)____[insert letter(s) of plan(s) being offered]
These charts show the benefits included in each of the 1990 standardized Medicare supplement plans. Every company must make available Plan A. Some plans may not be available in your state. New 1990 standardized benefit plans may not be issued on or after June 1, 2010.
See Outline of Coverage sections for details about ALL plans
Basic Benefits for Plans A-J:
Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.
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Medical Expenses: Part B coinsurance (generally 20% of Medicare-approved expenses), copayments for hospital outpatient services.
Blood: First three pints of blood each year.
Skilled Nursing Facility
Coinsurance
Skilled Nursing Facility
Coinsurance
Skilled Nursing Facility
Coinsurance
Part A Deductible Part A Deductible Part A Deductible Part A Deductible Part B Deductible Foreign Travel Emergency Foreign Travel Emergency Foreign Travel Emergency At-Home Recovery Preventive Care NOT covered by Medicare Skilled Nursing FacilityCoinsurance Skilled Nursing FacilityCoinsurance
Skilled Nursing FacilityCoinsurance
Skilled Nursing FacilityCoinsurance
Skilled Nursing Facility Coinsurance
Part A Deductible Part A Deductible Part A Deductible Part A Deductible Part A Deductible Part B Deductible Part B Deductible Part B Excess (80%) Part B Excess (80%) Part B Excess (80%) Part B Excess (80%) Foreign Travel Emergency Foreign Travel Emergency Foreign Travel Emergency Foreign Travel Emergency Foreign Travel Emergency At-Home Recovery At-Home Recovery At-Home Recovery Preventive Care NOT covered by Medicare
* Plans F and J also have an option called a high deductible Plan F and a high deductible Plan J. These high deductible plans pay the same benefits as Plans F and J after one has paid a calendar year $2000 deductible. Benefits from high deductible Plans F and J will not begin until out-of-pocket expenses exceed $2000. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible.
[COMPANY NAME]
Outline of Medicare Supplement Coverage – Cover Page 2
Basic Benefits for Plans K and L: include similar services as Plans A-J, but cost-sharing for the basic benefits is at different levels.
Basic Benefits
100% of Part Ahospitalization coinsurance plus coverage for 365 days after Medicare benefits end50% hospice cost-sharing50% of Medicare-eligible expenses for the first three pints of blood50% Part B coinsurance, except 100% coinsurance for Part B preventive services
100% of Part A hospitalization coinsurance plus coverage for 365 days after Medicare benefits end 75% hospice cost-sharing 75% of Medicare-eligible expenses for the first three pints of blood75% Part B coinsurance, except 100% coinsurance for Part B preventive services Skilled Nursing Coinsurance 50% Skilled Nursing Facility Coinsurance 75% Skilled Nursing Facility Coinsurance Part A Deductible 50% Part A Deductible 75% Part A Deductible Part B Deductible Part B Excess (100%) Foreign Travel Emergency At-Home Recovery Preventive Care NOT covered by Medicare $[4620] Out of Pocket Annual Limit*** $[2310] Out of Pocket Annual Limit***
**Plans K and L provide for different cost-sharing for items and services than Plan A – J. Once you reach the annual limit, the plan pays 100% of the Medicare copayments, coinsurance, and deductibles for the rest of the calendar year. The out-of-pocket annual limit does NOT include charges from your provider that exceed Medicare-approved amounts, called “Excess Charges.” You will be responsible for paying excess charges.
***The out-of-pocket annual limit will increase each year for inflation.
See Outlines of Coverage for details and exceptions.
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Benefit Chart of Medicare Supplement Plans Sold with an effective date for coverage on or after June 1, 2010.
This chart shows the benefits included in each of the standard Medicare supplement plans. Every company must make Plan “A” available. Some plans may not be available in your state.
Plans E, H, I, and J are no longer available for sale. [This sentence shall not appear after June 1, 2011.]
Basic Benefits:
Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.
Medical Expenses: Part B coinsurance (generally 20% of Medicare- approved expenses), or copayments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of Part B coinsurance or copayments.
Blood: First three pints of blood each year.
Hospice: Part A coinsurance.
Basic, including 100% Part B coinsurance
Basic, including 100% Part B coinsurance
Basic, including 100% Part B coinsurance
Basic, including 100% Part B coinsurance
Basic, including 100% Part B coinsurance
Basic, including 100% Part B coinsurance Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance Part A Deductible Part A Deductible Part A Deductible Part A Deductible Part A Deductible Part B Deductible Part B Deductible Part B Excess (100%) Part B Excess (100%) Foreign Travel Emergency Foreign Travel Emergency Foreign Travel Emergency Foreign Travel Emergency
Hospitalization and preventive care paid at 100%; other basic benefits paid at 50%
Hospitalization and preventive care paid at 100%; other basic benefits paid at 75%
Basic, including 100% Part B coinsurance
Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit,and up to $50 copayment for ER
50% Skilled Nursing Facility Coinsurance
75% SkilledNursing Facility Coinsurance
SkilledNursing Facility Coinsurance SkilledNursing Facility Coinsurance 50% Part A Deductible 50% Part A Deductible 50% Part A Deductible 50% Part A Deductible Foreign Travel Emergency Foreign Travel Emergency Out-of-pocket limit $[4620]; paid at 100% after limit reached Out-of-pocket limit $[2310]; paid at 100% after limit reached
* Plan F also has an option called a High Deductible Plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year [$2000] deductible. Benefits from High Deductible Plan F will not begin until out-of-pocket expenses exceed [$2000]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible.
(10) Any accident and sickness insurance policy or certificate, other than a Medicare supplement policy; or a policy issued pursuant to a contract under section 1876 or section 1833 of the Federal Social Security Act (42 USC Sec. 1395, et seq.), disability income policy; basic, catastrophic, or major medical expense policy; single premium nonrenewable policy or other policy identified in ARM 6.6.503(2) issued for delivery in this state to persons eligible for Medicare by reason of age must be accompanied by a notice to the insureds under the policy that the policy is not a Medicare supplement policy or certificate. The notice must either be printed on or attached to the first page of the outline of coverage delivered to insureds under the policy, or if no outline of coverage is delivered, to the first page of the policy or certificate delivered to insureds. The notice must be in no less than 12 point type and must contain the following language: “THIS (POLICY OR CERTIFICATE) IS NOT A MEDICARE SUPPLEMENT (POLICY OR CERTIFICATE). If you are eligible for Medicare, review the Medicare Supplement Buyers Guide available from the company.”
(11) Applications provided to persons eligible for Medicare for the health insurance policies or certificates described in this rule shall disclose, using the applicable statement in Appendix C of the NAIC Model Regulation, which was incorporated by reference in ARM 6.6.519, the extent to which the policy duplicates Medicare. The disclosure statement shall be provided as a part of, or together with, the application for the policy or certificate.
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