18 Del. Admin. Code § 1501-11.0

Current through Register Vol. 28, No. 5, November 1, 2024

Section 1501-11.0 - Standard Medicare Supplement Benefit Plans for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery with an effective date on or After June 1, 2010

11.1 The following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this state with an effective date of coverage on or after June 1, 2010. No policy or certificate may be advertised, solicited, delivered or issued for delivery in this state as a Medicare supplement policy or certificate 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 18 Del.C. § 3403.

11.1.1 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 subsection 9.2 of this regulation.

11.1.2 If an issuer makes available any of the additional benefits described in subsection 9.3, or offers standardized benefit Plans K or L (as described in subsections 11.5.8 and 11.5.9 of this regulation), 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 subsection 11.1.1 of this regulation, a policy form or certificate form containing either standardized benefit Plan C (as described in subsection 11.5 .3 of this regulation) or standardized benefit Plan F (as described in subsection 11.5.5 of this regulation).

11.2 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 subsection 11.7 and in Section 13.0 of this regulation.

11.3 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 Section 4.0 of this regulation. Each benefit shall be structured in accordance with the format provided in subsections 8.1 .2 and 8.1.3 of this regulation; or, in the case of plans K or L, in subsections 11.5.8 or 11.5.9 of this regulation and list the benefits in the order shown. For purposes of this subsection, "structure, language, and format" means style, arrangement and overall content of a benefit.

11.4 In addition to the benefit plan designations required in subsection 11.3 of this regulation, an issuer may use other designations to the extent permitted by law.

11.5 Make-up of 2010 Standardized Benefit Plans:

11.5.1 Standardized Medicare supplement benefit Plan A shall include only the following: The basic (core) benefits as defined in subsection 9.2 of this regulation.

11.5.2 Standardized Medicare supplement benefit Plan B shall include only the following: The basic (core) benefit as defined in subsection 9.2 of this regulation, plus one hundred percent (100%) of the Medicare Part A deductible as defined in subsection 9.3.1 of this regulation.

11.5.3 Standardized Medicare supplement benefit Plan C shall include only the following: The basic (core) benefit as defined in subsection 9.2 of this regulation, plus one hundred percent (100%) of the Medicare Part A deductible, skilled nursing facility care, one hundred percent (100%) of the Medicare Part B deductible, and medically necessary emergency care in a foreign country as defined in subsections 9.3.1, 9.3.3, 9.3.4, 9.3.5 and 9.3.6 of this regulation, respectively.

11.5.4 Standardized Medicare supplement benefit Plan D shall include only the following: The basic (core) benefit (as defined in subsection 9.2 of this regulation), plus one hundred percent (100%) of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in an foreign country as defined in subsections 9.3.1, 9.3.3, and 9.3.6 of this regulation, respectively.

11.5.5 Standardized Medicare supplement [regular] Plan F shall include only the following: The basic (core) benefit as defined in subsection of this regulation, plus one hundred percent (100%) of the Medicare Part A deductible, the skilled nursing facility care, one hundred percent (100%) of the Medicare Part B deductible, one hundred percent (100%) of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in subsections 9.3.1, 9.3.3, 9.3.4, 9.3.5, and 9.3.6 of this regulation, respectively.

11.5.6 Standardized Medicare supplement Plan F With High Deductible shall include only the following: one hundred percent (100%) of covered expenses following the payment of the annual deductible set forth in subsection 11.5.6.2 of this regulation.

11.5.6.1 The basic (core) benefit as defined in subsection 9.2 of this regulation, plus one hundred percent (100%) of the Medicare Part A deductible, skilled nursing facility care, one hundred percent (100%) of the Medicare Part B deductible, one hundred percent (100%) of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in subsections 9.3.1, 9.3.3, 9.3.4, 9.3.5, and 9.3.6 of this regulation, respectively.

11.5.6.2 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 twelve-month period ending with August of the preceding year, and rounded to the nearest multiple of ten dollars ($10).

11.5.7 Standardized Medicare supplement benefit Plan G shall include only the following: The basic (core) benefit as defined in subsection 9.2 of this regulation, plus one hundred percent (100%) of the Medicare Part A deductible, skilled nursing facility care, one hundred percent (100%) of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in subsections 9.3.1, 9.3.3, 9.3.5, and 9.3.6 of this regulation, respectively. Effective January 1, 2020, the standardized benefit plans described in subsection 12.1.4 of this regulation (re-designated Plan G High Deductible) may be offered to any individual who was eligible for Medicare prior to January 1, 2020.

11.5.8 Standardized Medicare supplement Plan K is mandated by The Medicare Prescription Drug, Improvement and Modernization Act of 2003, and shall include only the following:

11.5.8.1 Part A Hospital Coinsurance 61st through 90th days: Coverage of one hundred percent (100%) of the Part A hospital coinsurance amount for each day used from the 61st through the 90th day in any Medicare benefit period;

11.5.8.2 Part A Hospital Coinsurance, 91st through 150th days: Coverage of one hundred percent (100%) of the Part A hospital coinsurance amount for each Medicare lifetime inpatient reserve day used from the 91st through the 150th day in any Medicare benefit period;

11.5.8.3 Part A Hospitalization After 150 Days: Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of one hundred percent (100%) of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system (PPS) rate, or other appropriate Medicare standard of payment, subject to a lifetime maximum benefit of an additional 365 days. The provider shall accept the issuer's payment as payment in full and may not bill the insured for any balance;

11.5.8.4 Medicare Part A Deductible: Coverage for fifty percent (50%) of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in subsection 11.5.8.10 of this regulation;

11.5.8.5 Skilled Nursing Facility Care: Coverage for fifty percent (50%) of the coinsurance amount for each day used from the 21^st day through the 100^th 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 subsection 11.5.8.10 of this regulation;

11.5.8.6 Hospice Care: Coverage for fifty percent (50%) of cost sharing for all Part A Medicare eligible expenses and respite care until the out-of-pocket limitation is met as described in subsection 11.5.8.10 of this regulation;

11.5.8.7 Blood: Coverage for fifty percent (50%), under Medicare Part A or B, of the reasonable cost of the first three (3) pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulations) unless replaced in accordance with federal regulations until the out-of-pocket limitation is met as described in subsection 11.5.8.10 of this regulation;

11.5.8.8 Part B Cost Sharing: Except for coverage provided in subsection 11.5.8.9 of this regulation, coverage for fifty percent (50%) of the cost sharing otherwise applicable under Medicare Part B after the policyholder pays the Part B deductible until the out-of-pocket limitation is met as described in subsections 11.5.8.9 and 11.5.8.10 of this regulation;

11.5.8.9 Part B Preventive Services: Coverage of one hundred percent (100%) of the cost sharing for Medicare Part B preventive services after the policyholder pays the Part B deductible; and

11.5.8.10 Cost Sharing After Out-of-Pocket Limits: Coverage of one hundred percent (100%) of all cost sharing under Medicare Parts A and B for the balance of the calendar year after the individual has reached the out-of-pocket limitation on annual expenditures under Medicare Parts A and B of $4000 in 2006, indexed each year by the appropriate inflation adjustment specified by the Secretary of the U.S. Department of Health and Human Services.

11.5.9 Standardized Medicare supplement Plan L is mandated by The Medicare Prescription Drug, Improvement and Modernization Act of 2003, and shall include only the following:

11.5.9.1 The benefits described in subsections 11.5.8.1, 11.5.8.2, 11.5.8.3 and 11.5.8.9 of this regulation;

11.5.9.2 The benefit described in subsections 11.5.8.4, 11.5.8.5, and 11.5.8.8 of this regulation, respectively, but substituting seventy-five percent (75%) for fifty percent (50%); and

11.5.9.3 The benefit described in subsection 11.5.8.10 of this regulation, but substituting $2000 for $4000.

11.5.10 Standardized Medicare supplement Plan M shall include only the following: The basic (core) benefit as defined in subsection 9.2 of this regulation, plus fifty percent (50%) of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in subsections 9.3.2, 9.3.3 and 9.3.6 of this regulation, respectively.

11.5.11 Standardized Medicare supplement Plan N shall include only the following: The basic (core) benefit as defined in subsection 9.2 of this regulation, plus one hundred percent (100%) of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in subsections 9.3.1, 9.3.3 and 9.3.6 of this regulation, respectively, with co-payments in the following amounts:

11.5.11.1 The lesser of twenty dollars ($20) or the Medicare Part B coinsurance or co-payment for each covered health care provider office visit (including visits to medical specialists); and

11.5.11.2 The lesser of fifty dollars ($50) or the Medicare Part B coinsurance or co-payment for each covered emergency room visit, however, this co payment shall be waived if the insured is admitted to any hospital and the emergency visit is subsequently covered as a Medicare Part A expense.

11.6 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 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 must 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.

18 Del. Admin. Code § 1501-11.0

22 DE Reg. 1026 (6/1/2019) (final)