Current through Register Vol. 54, No. 49, December 7, 2024
Section 89.776a - Benefit standards for policies or certificates issued or delivered on or after June 1, 2010The following standards apply to 2010 Standardized Medicare supplement benefit plans. An issuer may not offer any 1990 Standardized Medicare supplement benefit plan for sale on or after June 1, 2010. A policy or certificate may not be advertised, solicited, delivered or issued for delivery in this Commonwealth as a Medicare supplement policy or certificate unless it complies with these benefit standards.
(1)General standards. The following standards apply to Medicare supplement policies and certificates and are in addition to all other requirements of this regulation. (i)Exclusions or limitations. A Medicare supplement policy or certificate may not exclude or limit benefits for losses incurred more than 6 months after the effective date of coverage because it involved a preexisting condition. The policy or certificate may 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 6 months before the effective date of coverage.(ii)Indemnification of sickness and accidents. A Medicare supplement policy or certificate may not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents.(iii)Cost sharing amounts under Medicare. 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 these changes.(iv)Termination of coverage . A Medicare supplement policy or certificate may not 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.(v)Cancellation or nonrenewal of policy. Each Medicare supplement policy is guaranteed renewable.(A) The issuer may not cancel or nonrenew the policy solely on the ground of health status of the individual.(B) The issuer may not cancel or nonrenew the policy for any reason other than nonpayment of premium or material misrepresentation.(C) If the Medicare supplement policy is terminated by the group policyholder and is not replaced as provided under clause (E), the issuer shall offer certificateholders an individual Medicare supplement policy which, at the option of the certificateholder, does one of the following: (I) Provides for continuation of the benefits contained in the group policy.(II) Provides for benefits that otherwise meet the requirements of this section.(D) If an individual is a certificateholder in a group Medicare supplement policy and the individual terminates membership in the group, the issuer shall do one of the following:(I) Offer the certificate holder the conversion opportunity described in clause (C).(II) At the option of the group policyholder, offer the certificateholder continuation of coverage under the group policy.(E) 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 may not result in an exclusion for preexisting conditions that would have been covered under the group policy being replaced.(vi)Extension of benefits. Termination of a Medicare supplement policy or certificate is without prejudice to any continuous loss which began while the policy was in force, but the extension of benefits beyond the period during which the 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 a continuous loss.(vii)Suspension by policyholder.(A) 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 certificateholder for the period (not to exceed 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 (42 U.S.C.A. §§ 1396-1396u), but only if the policyholder or certificateholder notifies the issuer of the policy or certificate within 90 days after the date the individual becomes entitled to this assistance.(B) If a suspension occurs and if the policyholder or certificateholder 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 certificateholder provides notice of loss of entitlement within 90 days after the date of loss and pays the premium attributable to the period, effective as of the date of the termination of entitlement.(C) Each Medicare supplement policy shall provide that benefits and premiums under the policy shall be suspended at the request of the policyholder if the policyholder is entitled to benefits under section 226(b) of the Social Security Act (42 U.S.C.A. § 426(b)) and is covered under a group health plan (as defined in section 1862 (b)(1)(A)(v) of the Social Security Act (42 U.S.C.A. § 1395y(b)(1)(A)(v)). If suspension occurs and if the policyholder or certificateholder loses coverage under the group health plan, the policy shall be automatically reinstituted (effective as of the date of loss of coverage) if the policyholder provides notice of loss of coverage within 90 days after the date of the loss and pays the premium attributable to the period, effective as of the date of termination of enrollment in the group health plan.(D) Reinstitution of coverages as described in clauses (B) and (C): (I) May not provide for any waiting period with respect to treatment of preexisting conditions.(II) Shall provide for resumption of coverage that is substantially equivalent to coverage in effect before the date of suspension.(III) Shall provide for classification of premiums on terms at least as favorable to the policyholder or certificateholder as the premium classification terms that would have applied to the policyholder or certificateholder if the coverage had not been suspended.(2)Standards for basic (core) benefits common to benefit Plans A-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 shall also offer a policy or certificate to prospective insureds meeting the Plan B benefit plan. An issuer may also make available to prospective insureds any Medicare Supplement Insurance Benefit Plan in addition to the basic core package, but not instead of it. The core packages are as follows:(i) Coverage of Part A Medicare eligible expenses for hospitalization to the extent not covered by Medicare from day 61 through day 90 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 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 365 days. The provider shall accept the issuer's payment as payment in full and may not bill the insured for any balance.(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.(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.(vi) Coverage of cost sharing for all Part A Medicare eligible hospice care and respite care expenses.(3)Standards for additional benefits. The following additional benefits shall be included in Medicare supplement benefit Plans B-D, F, F with High Deductible, G, M and N as provided by § 89.777b (relating to Standard Medicare supplement benefit plans for 2010 Standardized Medicare supplement benefit plan policies or certificates issued or delivered on or after June 1, 2010).(i)Medicare Part A deductible. Coverage for 100% of the Medicare Part A inpatient hospital deductible amount per benefit period.(ii)Medicare Part A deductible. Coverage for 50% of the Medicare Part A inpatient hospital deductible amount per benefit period.(iii)Skilled nursing facility care. Coverage for the actual billed charges up to the coinsurance amount from day 21 through day 100 in a Medicare benefit period for posthospital skilled nursing facility care eligible under Medicare Part A.(iv)Medicare Part B deductible. Coverage for 100% of the Medicare Part B deductible amount per calendar year regardless of hospital confinement.(v)Medicare Part B excess charges. Coverage for 100% of the difference between the Medicare Part B charges billed, not to exceed a charge limitation established by the Medicare program or state law including the Health Care Practitioner Medicare Fee Control Act (35 P. S. §§ 449.31-449.36), and the Medicare-approved Part B charge.(vi)Medically necessary emergency care in a foreign country. Coverage to the extent not covered by Medicare for 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 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" means care needed immediately because of an injury or an illness of sudden and unexpected onset.The provisions of this § 89.776a adopted April 24, 2009, effective 4/25/2009, 39 Pa.B. 2086.The provision of this § 89.776a issued under sections 206, 506, 1501 and 1502 of The Administrative Code of 1929 (71 P. S. §§ 66, 186, 411 and 412), the Medicare Improvements for Patients and Providers Act of 2008, Pub. L. No. 100-275, 122 Stat. 2494 and the Genetic Information Nondiscrimination Act of 2008, Pub. L. No. 110-233, 122 Stat. 881.
This section cited in 31 Pa. Code § 89.774 (relating to exclusions and limitations); 31 Pa. Code § 89.775 (relating to minimum benefit standards for policies or certificates issued for delivery prior to July 30, 1992); and 31 Pa. Code § 89.777b (relating to standard Medicare supplement benefit plans for 2010 standardized Medicare supplement benefit plan policies or certificates issued or delivered on or after June 1, 2010).