N.Y. Comp. Codes R. & Regs. tit. 11 § 52.26

Current through Register Vol. 46, No. 45, November 2, 2024

Section 52.26 - Rules relating to exclusion of medicare benefits

Subject to sections 3216 (c), 4235 (f), 4304 (d), 4304 (e)(1)-(3) and 4305 (d)(1) of the Insurance Law, the following rules shall apply to provisions with respect to Medicare:

(a) Policies may provide for termination of coverage upon eligibility for Medicare by reason of age only. An exception to this rule is subject to approval by the superintendent, and will be considered only if:

(1) the insurer offers conversion to a Medicare supplement contract;

(2) the conversion contract plus Medicare provide the same or greater benefits for the same or lesser premium than the original contract plus Medicare would have provided; and

(3) the insurer provides that the insured can obtain, without evidence of insurability and without limitations as to preexisting conditions, the same or similar coverage as that in the original contract in the event Medicare coverage ceases.

(b) Policies may limit benefit periods with respect to a covered person, effective when such person is eligible for Medicare by reason of age. Changes in existing policies must be accompanied, where appropriate, by a suitable adjustment in the premiums.

(c) Policies may provide for the exclusion of Medicare benefits when coverage continues beyond the covered person's eligibility for Medicare benefits, provided appropriate adjustment is made in the premium.

(d) Where group coverage terminates upon retirement, insurers may insert a Medicare exclusion applicable to employees who continue to work after the date of eligibility for Medicare.

(e) Eligibility for coverage under Medicare by reason of age constitutes a proper basis, under sections 3221 (e), 3216 (c) (g), 4303, 4304, 4305 and 4306 of the Insurance Law, for determining overinsurance, or duplication of benefits, for purposes of refusal to renew, refusal to issue a conversion policy and for limiting renewals to the date of eligibility for Medicare.

N.Y. Comp. Codes R. & Regs. Tit. 11 § 52.26