N.Y. Comp. Codes R. & Regs. tit. 11 § 58.2

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

Section 58.2 - Rules relating to the standard medicare supplement benefit plans and the make-up of medicare supplement benefit plans issued for an effective date of coverage prior to june 1, 2010

(a) General applicability. The following shall be applicable to Medicare supplement insurance and Medicare select as defined in sections 52.11 and 52.14 of this Title, respectively, and shall be in addition to other requirements of this Part. Such rules shall apply to all Medicare supplement and Medicare select policies and certificates issued with an effective date for coverage prior to June 1, 2010 in this State. 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 with an effective date for coverage on or after June 1, 2010 are subject to the requirements of section 58.4 of this Part.

(b) Standard Medicare supplement benefit plans issued with an effective date for coverage prior to June 1, 2010.

(1) 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 subparagraph (6)(xi) of this subdivision.

(2) Where a nonprofit health service, hospital service or medical expense indemnity corporation issues a subscriber contract which does not include all of the benefits required for a plan of Medicare supplement insurance, such contract must, in order to qualify as Medicare supplement insurance, be issued in conjunction with another contract including the remainder of the benefits required for a plan of Medicare supplement insurance as prescribed in this section. In the alternative, two or more of such corporations may act jointly and issue a single contract which contains all of the benefits required for a plan of Medicare supplement insurance.

(3) Benefit plans shall be uniform in structure, language, designation and format to the standard benefit plans "A'' through "L'' listed in subdivision (c) of this section and conform to the definitions in section 58.1(a) of this Part. Each benefit plan shall be structured in accordance with the format provided in paragraphs (5) and (6) of this subdivision and list the benefits in the order shown in subdivision (c) of this section. For purposes of this section, structure, language, and format means style, arrangement and overall content of a benefit.

(4) An issuer may use, in addition to the benefit plan designations required in paragraph (3) of this subdivision, other designations to the extent permitted by law or regulation.

(5) Benefit plans A-J shall include the following basic "core'' benefits:

(i) coverage of Part A Medicare eligible expenses for hospitalization to the extent not covered by Medicare from the 61st day through the 90th day in any Medicare benefit period;

(ii) 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;

(iii) upon exhaustion of Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 100 percent of the costs incurred for hospitalization expenses of the kind covered by Medicare and recognized as medically necessary by Medicare, subject to a lifetime maximum benefit of an additional 365 days. The issuer may enter into reimbursement contracts with provider hospitals to stand in the place of Medicare and to make payment for the hospitalization expenses at the applicable prospective payment system (PPS) rate or other appropriate Medicare standard of payment, so long as there continues to be no cost to the insured person;

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

(v) 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) The following additional benefits shall be included in Medicare supplement benefit plans "B'' through "J'' only, as provided by subdivision (c) of this section.

(i) Medicare Part A deductible. Coverage for all of the Medicare Part A inpatient hospital deductible amount per benefit period.

(ii) Skilled nursing facility care. Coverage for the actual billed charges up to the coinsurance amount from the 21st day through the 100th day in a Medicare benefit period for post hospital skilled nursing facility care eligible under Medicare Part A.

(iii) Medicare Part B deductible. Coverage for all of the Medicare Part B deductible amount per calendar year regardless of hospital confinement.

(iv) 80 percent of the Medicare Part B excess charges. Coverage for 80 percent of the difference between the actual Medicare Part B charge as billed, not to exceed any charge limitation established by the Medicare program or State law, and the Medicare-approved Part B charge.

(v) 100 percent of the Medicare Part B excess charges. Coverage for all of the difference between the actual Medicare Part B charge as billed, not to exceed any charge limitation established by the Medicare program or State law, and the Medicare-approved Part B charge.

(vi) Basic outpatient prescription drug benefit. Coverage for 50 percent of outpatient prescription drug charges, after a $250 calendar year deductible, to a maximum of $1,250 in benefits received by the insured per calendar year, to the extent not covered by Medicare. The outpatient prescription drug benefit may be included for sale or issuance in a Medicare supplement policy until January 1, 2006.

(vii) Extended outpatient prescription drug benefit. Coverage for 50 percent of outpatient prescription drug charges, after a $250 calendar year deductible to a maximum of $3,000 in benefits received by the insured per calendar year, to the extent not covered by Medicare. The outpatient prescription drug benefit may be included for sale or issuance in a Medicare supplement policy until January 1, 2006.

(viii) Medically necessary emergency care in a foreign country. Coverage to the extent not covered by Medicare for 80 percent 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 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.

(ix) Preventive medical care benefit. Coverage for the following preventive health services not covered by Medicare:

(a) An annual clinical preventive medical history and physical examination that may include tests and services from clause (b) of this subparagraph and patient education to address preventive health care measures.

(b) Preventive screening tests or preventive services, the selection and frequency of which is determined to be medically appropriate by the attending physician.

Reimbursement shall be for the actual charges up to 100 percent of the Medicare-approved amount for each service, as if Medicare were to cover the service as identified in American Medical Association Current Procedural Terminology (AMACPT) codes, to a maximum of $120 annually under this benefit. This benefit shall not include payment for any procedure covered by Medicare.

(x) At-home recovery benefit. Coverage for services to provide short term, at-home assistance with activities of daily living for those recovering from an illness, injury or surgery.

(a) For purposes of this benefit, the following definitions shall apply:

(1) Activities of daily living include, but are not limited to bathing, dressing, personal hygiene, transferring, eating, ambulating, assistance with drugs that are normally self-administered, and changing bandages or other dressings.

(2) Care provider means a duly qualified or licensed home health aide or homemaker, personal care aide or nurse provided through a licensed home health care agency or referred by a licensed referral agency or licensed nurses' registry.

(3) Home shall mean any place used by the insured as a place of residence, provided that such place would qualify as a residence for home health care services covered by Medicare. A hospital or skilled nursing facility shall not be considered the insured's place of residence.

(4) At-home recovery visit means the period of a visit required to provide at- home recovery care, without limit on the duration of the visit, except each consecutive four hours in a 24-hour period of services provided by a care provider is one visit.

(b) Coverage requirements and limitations:

(1) At-home recovery services provided must be primarily services which assist in activities of daily living.

(2) The insured's attending physician must certify that the specific type and frequency of at-home recovery services are necessary because of a condition for which a home care plan of treatment was approved by Medicare.

(3) Coverage is limited to:

(i) no more than the number and type of at-home recovery visits certified as necessary by the insured's attending physician. The total number of at-home recovery visits shall not exceed the number of Medicare approved home health care visits under a Medicare approved home care plan of treatment;

(ii) the actual charges for each visit up to a maximum reimbursement of $40 per visit;

(iii) $1,600 per calendar year;

(iv) seven visits in any one week;

(v) care furnished on a visiting basis in the insured's home;

(vi) services provided by a care provider as defined in this section;

(vii) at-home recovery visits while the insured is covered under the policy or certificate and not otherwise excluded; and

(viii) at-home recovery visits received during the period the insured is receiving Medicare approved home care services or no more than eight weeks after the service date of the last Medicare approved home health care visit.

(c) Coverage is excluded for:

(1) home care visits paid for by Medicare or other government programs; and

(2) care provided by family members, unpaid volunteers or providers who are not care providers.

(xi) New or innovative benefits. An issuer may, with the prior approval of the superintendent, offer policies or certificates with new or innovative benefits in addition to the benefits provided in a policy or certificate that otherwise complies with the applicable standards. Such new or innovative benefits may include benefits that are appropriate to Medicare supplement insurance, new or innovative, not otherwise available, cost-effective, and offered in a manner which is consistent with the goal of simplification of Medicare supplement policies. After December 31, 2005, the innovative benefit shall not include an outpatient prescription drug benefit.

(7)

(i) Every issuer shall make available both standardized Medicare supplement insurance benefit plans "A'' and "B,'' as defined in paragraphs (c)(1) and (2) of this section, to each prospective policyholder and certificateholder. An issuer may make available to prospective policyholders and certificateholders any of the other Medicare supplement insurance benefit plans permitted by this section in addition to benefit plans "A" and "B,'' but not in lieu thereof.

(ii) Every issuer shall permit its policyholders and certificateholders to terminate existing coverage and replace it with any other Medicare supplement insurance benefit plan then being made available to prospective policyholders and certificateholders by the issuer. An issuer may limit changes in coverage initiated by a policyholder or certificateholder to an anniversary date or other regular interval, so long as the interval is not less than once every 12 months.

(c) Make-up of Medicare supplement benefit plans issued with an effective date for coverage prior to June 1, 2010.

(1) Standardized Medicare supplement benefit plan "A'' shall be limited to the basic ("core'') benefits common to all benefit plans, as defined in paragraph (b)(5) of this section.

(2) Standardized Medicare supplement benefit plan "B'' shall include only the following: the core benefits as defined in paragraph (b)(5) of this section, plus the Medicare Part A deductible as defined in subparagraph (b)(6)(i) of this section.

(3) Standardized Medicare supplement benefit plan "C'' shall include only the following: the core benefits as defined in paragraph (b)(5) of this section, plus the Medicare Part A deductible, skilled nursing facility care, Medicare Part B deductible and medically necessary emergency care in a foreign country as defined in subparagraphs (b)(6)(i), (ii), (iii) and (viii) of this section.

(4) Standardized Medicare supplement benefit plan "D'' shall include only the following: the core benefit as defined in paragraph (b)(5) of this section, plus the Medicare Part A deductible, skilled nursing facility care, medically necessary emergency care in a foreign country and the at-home recovery benefit as each is defined in subparagraphs (b)(6)(i), (ii), (viii) and (x) of this section.

(5) Standardized Medicare supplement benefit plan "E'' shall include only the following: the core benefit as defined in paragraph (b)(5) of this section, plus the Medicare Part A deductible, skilled nursing facility care, medically necessary emergency care in a foreign country and preventive medical care as defined in subparagraphs (b)(6)(i), (ii), (viii) and (ix) of this section.

(6) Standardized Medicare supplement benefit plan "F'' shall include only the following: the core benefits as defined in paragraph (b)(5) of this section, plus the Medicare Part A deductible, the skilled nursing facility care, the Medicare Part B deductible, 100 percent of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in subparagraphs (b)(6)(i), (ii), (iii), (v) and (viii) of this section.

(7) Standardized Medicare supplement benefit high deductible plan "F" shall include only the following: 100 percent of covered expenses following the payment of the annual high deductible plan "F" deductible. The covered expenses include the core benefits as defined in paragraph (b)(5) of this section, plus the Medicare Part A deductible, skilled nursing facility care, the Medicare Part B deductible, 100 percent of the Medicare Part B excess charges and medically necessary emergency care in a foreign country as defined in subparagraphs (b)(6)(i) through (iii), (v) and (viii) of this section. The annual high deductible plan "F'' deductible shall consist of out-of-pocket expenses, other than premiums, for services covered by the Medicare supplement plan "F'' policy, and shall be in addition to any other specific benefit deductibles. The annual high deductible plan "F'' deductible shall be $1,500 for 1998 and 1999, and shall be based on the calendar year. Such deductible shall be adjusted annually thereafter by the secretary to reflect the change in the Consumer Price Index for all urban consumers for the 12-month period ending with August of the preceding year, and rounded to the nearest multiple of $10. For example, the annual deductible for Medicare supplement benefit high deductible plan "F" for 2010 is $2,000.

(8) Standardized Medicare supplement benefit plan "G" shall include only the following: the core benefit as defined in paragraph (b)(5) of this section, plus the Medicare Part A deductible, skilled nursing facility care, 80 percent of the Medicare Part B excess charges, medically necessary emergency care in a foreign country, and the at-home recovery benefit as each is defined in subparagraphs (b)(6)(i), (ii), (iv), (viii) and (x) of this section.

(9) Standardized Medicare supplement benefit plan "H" shall consist of only the following: the core benefit as defined in paragraph (b)(5) of this section, plus the Medicare Part A deductible, skilled nursing facility care, basic outpatient prescription drug benefit and medically necessary emergency care in a foreign country as each is defined in subparagraphs (b)(6)(i), (ii), (vi) and (viii) of this section. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005.

(10) Standardized Medicare supplement benefit plan "I" shall consist of only the following: the core benefits as defined in paragraph (b)(5) of this section, plus the Medicare Part A deductible, skilled nursing facility care, 100 percent of the Medicare Part B excess charges, basic outpatient prescription drug benefit, medically necessary emergency care in a foreign country and at-home recovery benefit as each is defined in subparagraphs (b)(6)(i), (ii), (v), (vi), (viii) and (x) of this section. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005.

(11) Standardized Medicare supplement benefit plan "J" shall consist of only the following: the core benefit as defined in paragraph (b)(5) of this section, plus the Medicare Part A deductible, skilled nursing facility care, Medicare Part B deductible, 100 percent of the Medicare Part B excess charges, extended outpatient prescription drug benefit, medically necessary emergency care in a foreign country, preventive medical care and at-home recovery benefit as each is defined in subparagraphs (b)(6)(i), (ii), (iii), (v), (vii), (viii), (ix) and (x) of this section. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005.

(12) Standardized Medicare supplement benefit high deductible plan "J" shall consist of only the following: 100 percent of covered expenses following the payment of the annual high deductible plan "J" deductible. The covered expenses include the core benefit as defined in paragraph (b)(5) of this section, plus the Medicare Part A deductible, skilled nursing facility care, Medicare Part B deductible, 100 percent of the Medicare Part B excess charges, extended outpatient prescription drug benefit, medically necessary emergency care in a foreign country, preventive medical care and at-home recovery benefit as defined in subparagraphs (b)(6)(i) through (iii), (v) and (vii) through (x) of this section. The annual high deductible plan "J" deductible shall consist of out-of-pocket expenses, other than premiums, for services covered by the Medicare supplement plan "J" policy, and shall be in addition to any other specific benefit deductibles. The annual high deductible plan "J" deductible shall be $1,500 for 1998 and 1999, and shall be based on a calendar year. Such deductible shall be adjusted annually thereafter by the secretary to reflect the change in the Consumer Price Index for all urban consumers for the 12-month period ending with August of the preceding year, and rounded to the nearest multiple of $10. For example, the annual deductible for Medicare supplement benefit high deductible plan "J" for 2010 is $2,000. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005.

(13) Standardized Medicare supplement benefit plan "K" shall include only the following:

(i) coverage of 100 percent of the Part A hospital coinsurance amount for each day used from the 61st through the 90th day in any Medicare benefit period;

(ii) coverage of 100 percent 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;

(iii) upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 100 percent of the costs incurred for hospitalization expenses of the kind covered by Medicare and recognized as medically necessary by Medicare, subject to a lifetime maximum benefit of an additional 365 days. The issuer may enter into reimbursement contracts with provider hospitals to stand in the place of Medicare and to make payment for the hospitalization expenses at the applicable prospective payment system (PPS) rate or other appropriate Medicare standard of payment, so long as there continues to be no cost to the insured person;

(iv) Medicare Part A deductible. Coverage for 50 percent of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in subparagraph (x) of this paragraph;

(v) skilled nursing facility care. Coverage for 50 percent of the coinsurance amount for each day used from the 21st day through the 100th 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 subparagraph (x) of this paragraph;

(vi) hospice care. Coverage for 50 percent of cost sharing for all Part A Medicare eligible expenses and respite care until the out-of-pocket limitation is met as described in subparagraph (x) of this paragraph;

(vii) coverage for 50 percent under Medicare Part A or B, of the reasonable cost of the first three 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 subparagraph (x) of this paragraph;

(viii) except for coverage provided in subparagraph (ix) of this paragraph, coverage for 50 percent 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 subparagraph (x) of this paragraph;

(ix) coverage of 100 percent of the cost sharing for Medicare Part B preventive services after the policyholder pays the Part B deductible; and

(x) coverage of 100 percent 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 $4,620 in 2010, indexed each year by the appropriate inflation adjustment specified by the secretary.

(14) Standardized Medicare supplement benefit plan "L'' shall include only the following:

(i) the benefits described in subparagraphs (13)(i), (ii), (iii) and (ix) of this subdivision;

(ii) the benefit described in subparagraphs (13)(iv), (v), (vi), (vii) and (viii) of this subdivision, but substituting 75 percent for 50 percent; and

(iii) the benefit described in subparagraph (13)(x) of this subdivision, but substituting $2,310 for $4,620.

N.Y. Comp. Codes R. & Regs. Tit. 11 § 58.2