N.M. Admin. Code § 13.10.25.13

Current through Register Vol. 35, No. 24, December 23, 2024

Section 13.10.25.13 - BENEFIT STANDARDS FOR 2010 STANDARDIZED MEDICARE SUPPLEMENT BENEFIT PLAN POLICIES OR CERTIFICATES ISSUED FOR DELIVERY WITH AN EFFECTIVE DATE FOR COVERAGE ON OR AFTER JUNE 1, 2010

The following standards are applicable to all Medicare Supplement policies or certificates delivered or issued for delivery in this state with an effective date for coverage on or after June 1, 2010. No policy or certificate may be advertised, solicited, delivered, or issued for delivery in this state as a Medicare Supplement policy 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 with an effective date of coverage before June 1, 2010 remain subject to the requirements of 13.10.25.11 NMAC.

A.General standards. The following standards apply to 2010 Standardized Benefit Plan policies and certificates and are in addition to all other requirements of this regulation.

(1)Preexisting conditions. Refer to Paragraph (1) of Subsection A of 13.10.25.11 NMAC.

(2)Losses from sickness. Refer to Paragraph (2) of Subsection A of 13.10.25.11 NMAC.

(3)Cost sharing. Refer to Paragraph (3) of Subsection A of 13.10.25.11 NMAC.

(4)Termination of spousal coverage. Refer to Paragraph (4) of Subsection A of 13.10.25.11 NMAC.

B.Renewal and continuation of coverage for policies or certificates. Each Medicare Supplement policy shall be guaranteed renewable.

(1)Cancellation for health status. Refer to Paragraph (1) of Subsection B of 13.10.25.11 NMAC.

(2)Cancellation by issuer. Refer to Paragraph (2) of Subsection B of 13.10.25.11 NMAC.

(3)Termination by group. Refer to Paragraph (3) of Subsection B of 13.10.25.11 NMAC.

(4)Group membership termination. Refer to Paragraph (4) of Subsection B of 13.10.25.11 NMAC.

(5)Replacement. Refer to Paragraph (5) of Subsection B of 13.10.25.11 NMAC.

(6)Coverage of continuous loss. Refer to Paragraph (6) of Subsection B of 13.10.25.11 NMAC.

C.Coordination with medical assistance under Title XIX of the Social Security Act. Refer to Subsection C of 13.10.25.11 NMAC.

D.Standards for basic (core) benefits common to Medicare Supplement insurance benefit plans A, B, C, D, F, F with high deductible, G, M and N: Every issuer shall make available a policy or certificate including only the following basic "core" package of benefits to each prospective insured. An issuer may make available to prospective insureds any of the other Medicare Supplement insurance benefit plans in addition to the basic core package, but not in lieu of it.

(1)Medicare Part A coinsurance after day 60. Refer to Paragraph (1) of Subsection E of 13.10.25.11 NMAC;

(2)Medicare Part A reserve lifetime days coinsurance. Refer to Paragraph (2) of Subsection E of 13.10.25.11 NMAC;

(3)Medicare Part A uncovered hospitalization coverage. Refer to Paragraph (3) of Subsection E of 13.10.25.11 NMAC;

(4)Medicare Part A and Medicare Part B blood. Refer to Paragraph (4) of Subsection E of 13.10.25.11 NMAC;

(5)Medicare Part B cost sharing. Refer to Paragraph (5) of Subsection E of 13.10.25.11 NMAC; and

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

E.Standards for additional benefits: The following additional benefits shall be included in Medicare Supplement benefit Plans B, C, D, F, F with High Deductible, G, M, and N as provided by 13.10.25.14 NMAC.

(1) Medicare Part A deductible, one-hundred percent. Refer to Paragraph (1) of Subsection F of 13.10.25.11 NMAC;

(2)Medicare Part A deductible, fifty percent. Coverage for fifty percent of the Medicare Part A inpatient hospital deductible amount per benefit period.

(3)Skilled nursing facility care. Refer to Paragraph (2) of Subsection F of 13.10.25.11 NMAC.

(4)Medicare Part B deductible. Refer to Paragraph (3) of Subsection F of 13.10.25.11 NMAC;

(5)One-hundred percent of the Medicare Part B excess charges. Refer to Paragraph (5) of Subsection F of 13.10.25.11 NMAC; and

(6)Medically necessary emergency care in a foreign country. Refer to Paragraph (8) of Subsection F of 13.10.25.11 NMAC.

F.Standards for Plans K and L.

(1)Plan K. Plan K as mandated by the Medicare Prescription Drug, Improvement and Modernization Act of 2003, shall include only the following:

(a)Medicare Part A coinsurance after day 60. Refer to Subparagraph (a) of Paragraph (1) of Subsection G of 13.10.25.11 NMAC;

(b)Medicare Part A hospital coinsurance, 91st through 150th days. Refer to Subparagraph (b) of Paragraph (1) of Subsection G of 13.10.25.11 NMAC;

(c)Medicare Part A hospitalization after lifetime reserve days are exhausted. Refer to Subparagraph (c) of Paragraph (1) of Subsection G of 13.10.25.11 NMAC;

(d)Medicare Part A deductible. Refer to Subparagraph (d) of Paragraph (1) of Subsection G of 13.10.25.11 NMAC

(e)Skilled nursing facility care. Refer to Subparagraph (e) of Paragraph (1) of Subsection G of 13.10.25.11 NMAC;

(f)Hospice Care. Refer to Subparagraph (f) of Paragraph (1) of Subsection G of 13.10.25.11 NMAC;

(g)Blood. Refer to Subparagraph (g) of Paragraph (1) of Subsection G of 13.10.25.11 NMAC;

(h)Medicare Part B Cost sharing. Refer to Subparagraph (h) of Paragraph (1) of Subsection G of 13.10.25.11 NMAC;

(i)Medicare Part B preventive services. Refer to Subparagraph (i) of Paragraph (1) of Subsection G of 13.10.25.11 NMAC;

(j)Cost sharing after out-of-pocket limits. Refer to Subparagraph (j) of Paragraph (1) of Subsection G of 13.10.25.11 NMAC.

(2)Plan L. Plan L as mandated by the Medicare Prescription Drug Improvement and Modernization Act of 2003, shall include only the following:

(a) The benefits described in Subparagraphs (a), (b), (c) and (i) of the preceding paragraph;

(b) The benefit described in Subparagraphs (d), (e), (f), (g) and (h) of the preceding paragraph, but substituting seventy-five percent for fifty percent; and

(c) The benefit described in Subparagraph (j) of the preceding paragraph, but substituting $2000 for $4000.

N.M. Admin. Code § 13.10.25.13

13.10.25.13 NMAC - N, 08/31/09, Adopted by New Mexico Register, Volume XXIX, Issue 24, December 27, 2018, eff. 1/1/2019