D.C. Mun. Regs. tit. 26, r. 26-A2207a

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 26-A2207a - BENEFIT STANDARDS FOR 2010 STANDARDIZED MEDICARE SUPPLEMENT BENEFIT PLAN POLICIES OR CERTIFICATES ISSUED FOR DELIVERY ON OR AFTER JUNE 1, 2010

2207a-1 The following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in the District on or after June 1, 2010.

2207a-2 No policy or certificate may be advertised, solicited, delivered, or issued for delivery in the District as a Medicare supplement policy or certificate unless it complies with the benefit standards in this section.

2207a-3 No issuer may offer any 1990 standardized plan for sale on or after June 1, 2010.

2207a-4 Benefit standards applicable to Medicare supplement policies and certificates issued before June 1, 2010, remain subject to the requirements of section 2207.

2207a-5 The following general standards in subsection 2207 a-6 through 2207a-23 apply to Medicare supplement policies and certificates and are in addition to all other requirements of this chapter.

2207a-6 A Medicare supplement policy or certificate shall not exclude or limit benefits for losses incurred more than six (6) months from the effective date of coverage because it involved a preexisting condition.

2207a-7 A Medicare supplement policy or certificate shall not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within six (6) months before the effective date of coverage.

2207a-8 A Medicare supplement policy or certificate shall not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents.

2207a-9 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.

2207a-10 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.

2207a-11 Each Medicare supplement policy shall be guaranteed renewable.

2207a-12 No Medicare supplement policy shall be canceled or non-renewed by the issuer solely on the ground of health status of the individual.

2207a-13 No Medicare supplement policy shall be canceled or non-renewed by the issuer for any reason other than nonpayment of premium or material misrepresentation.

2207a-14 If the Medicare supplement policy is terminated by the group policyholder and is not replaced under subsection 2207 a-16 of this chapter, the issuer shall offer certificate holders an individual Medicare supplement policy which, at the option of the certificate holder:

(a) Provides for continuation of the benefits contained in the group policy; or

(b) Provides for benefits that otherwise meet the requirements of this subsection.

2207a-15 If an individual is a certificate holder in a group Medicare supplement policy and the individual terminates membership in the group, the issuer shall:

(a) Offer the certificate holder the conversion opportunity described in subsection 2207 a-14; or

(b) At the option of the group policyholder, offer the certificate holder continuation of coverage under the group policy.

2207a-16 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 that is being replaced.

2207a-17 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 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 continuous loss.

2207a-18 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 twenty-four (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 ninety (90) days after the date the individual becomes entitled to assistance.

2207a-19 If suspension of benefits and premiums under a Medicare supplement policy or certificate 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 or entitlement within ninety (90) days after the date of loss and pays the premium attributable to the period, effective as of the date of termination of entitlement.

2207a-20 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 regulations) 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).

2207a-21 If suspension of benefits and premiums under a Medicare supplement policy or certificate 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 coverage) if the policyholder provides notice of loss of coverage within ninety (90) days after the date of loss.

2207a-22 Reinstitution of coverages as described in subsections 2207 a-19, 2207a-20 and 2207a-21 shall not provide for any waiting period with respect to treatment and preexisting conditions.

2207a-23 Reinstitution of coverages as described in subsections 2207 a-19, 2207a-20 and 2207a-21 shall:

(a) Provide for resumption of coverage that is substantially equivalent to coverage in effect before the date of suspension; and

(b) 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.

2207a-24 The following standards for Basic ("Core") Benefits common to Medicare Supplement Insurance Plans A, B, C, D, F, F with High Deductible, G, M, and N shall apply.

(a) Every issuer of a Medicare Supplement Insurance Benefits Plan shall make available a policy or certificate including only the following basic "core" package of benefits to each prospective insured:

(1) Coverage of Part A Medicare Eligible Expenses for hospitalization to the extent not covered by Medicare from the sixty-first (61^st) day through the ninetieth (90^th) 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 three hundred sixty-five (365) days; provided that the provider shall accept the issuers payment as payment in full and may not bill the insured for any balance;

(4) Coverage under Medicare Parts A and B for the reasonable cost of the first three (3) pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulations) unless replaced in accordance with federal regulations;

(5) Coverage for the coinsurance amount, or in the case of hospital outpatient department services paid under a prospective payment system, the copayment amount, of Medicare eligible expenses under Part B regardless of hospital confinement, subject to the Medicare Part B deductible;

(6) Coverage of cost sharing for all Part A Medicare eligible hospice care and respite care expenses.

(b) An issuer may make available to prospective insureds any of the other Medicare Supplement Insurance Benefit Plans in addition to the basic "core" package of benefits, but not in lieu of the basic "core" package of benefits.

2207a-25 The following additional benefits shall be included in Medicare Supplement Benefit Plans B, C, D, F, F with High Deductible, G, M, and N as provided by section 2208 a of this chapter.

(a) Medicare Part A Deductible: Coverage for one hundred percent (100%) of the Medicare Part A inpatient deductible amount per benefit period.

(b) Medicare Part A Deductible: Coverage for fifty percent (50%) of the Medicare Part A inpatient hospital deductible amount per benefit period.

(c) Skilled Nursing Facility Care: Coverage for the actual billed charges up to the coinsurance amount from the twenty-first (21^st) day through the one hundredth (100^th) day in a Medicare benefit period for post-hospital skilled nursing facility care eligible under Medicare Part A.

(d) Medicare Part B Deductible: Coverage for one hundred percent (100%) of the Medicare Part B deductible amount per calendar year regardless of hospital confinement.

(e) One Hundred Percent (100%) of the Medicare Part B Excess Charges: Coverage for all of the difference between the actual Medicare Part B charges as billed, not to exceed any charge limitation established by the Medicare program of District law, and the Medicare-approved Part B charge.

(f) Medically Necessary Emergency Care in a Foreign Country: Coverage to the extent not covered by Medicare for eighty percent (80%) of the billed charges for Medicare-eligible expenses for medically necessary emergency hospital, physician and medical care received in a foreign country, which care would have been covered by Medicare if provided in the United States and which care began during the first sixty (60) consecutive days of each trip outside the United States, subject to a calendar year deductible of $250, and a lifetime maximum benefit of $50,000. For purposes of this benefit, "emergency care" shall mean care needed immediately because of an injury or an illness of sudden and unexpected onset.

D.C. Mun. Regs. tit. 26, r. 26-A2207a

Final Rulemaking published at 56 DCR 8840 (November 13, 2009), incorporating text of Proposed Rulemaking published at 56 DCR 7661, 7664 (September 25, 2009)