Section 0780-01-58-.11 - STANDARD MEDICARE SUPPLEMENT BENEFIT PLANS FOR 2010 STANDARDIZED MEDICARE SUPPLEMENT BENEFIT PLAN POLICIES OR CERTIFICATES ISSUED FOR DELIVERY WITH AN EFFECTIVE DATE OF COVERAGE ON OR AFTER JUNE 1, 2010The following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this state with an effective date of 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 plan standards. Benefit plan 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 T.C.A. Title 56, Chapter 7, Part 14 and all applicable benefit standards in Rules 0780-01-58-.07 and 0780-01-58-.08 of this Chapter.
(1)(a) An issuer shall make available to each prospective policyholder and certificate holder a policy form or certificate form containing only the basic (core) benefits, as defined in Rule 0780-01-58-.09(2) of this Chapter.(b) If an issuer makes available any of the additional benefits described in Rule 0780-01-58-.09(3), or offers standardized benefit Plans K or L as described in subparagraphs (5)(h) and (i) of this Rule, then the issuer shall make available to each prospective policyholder and certificate holder, in addition to a policy form or certificate form with only the basic (core) benefits as described in subparagraph (1)(a), a policy form or certificate form containing either standardized benefit Plan C as described in subparagraph (5)(c), or standardized benefit Plan F as described in subparagraph (5)(e).(2) No groups, packages or combinations of Medicare supplement benefits other than those listed in this Rule shall be offered for sale in this state, except as may be permitted in Paragraph (6) and in Rule 0780-01-58-.13 of this Chapter.(3) Benefit plans shall be uniform in structure, language, designation and format to the standard benefit plans listed in this Rule and conform to the definitions in Rule 0780-01-58-.04 of this Chapter. Each benefit shall be structured in accordance with the format provided in Rules 0780-01-58-.09(2) and (3) of this Chapter; or, in the case of plans K or L, in subparagraphs (5)(h) or (i) and list the benefits in the order shown. For purposes of this Rule, "structure, language, and format" means style, arrangement and overall content of a benefit.(4) In addition to the benefit plan designations required in Paragraph (3), an issuer may use other designations to the extent permitted by law.(5) Make-up of 2010 Standardized Benefit Plans: (a) Standardized Medicare supplement benefit Plan A shall include only the following: The basic (core) benefits as defined in Rule 0780-01-58-.09(2) of this Chapter.(b) Standardized Medicare supplement benefit Plan B shall include only the following: The basic (core) benefit as defined in Rule 0780-01-58-.09(2) of this Chapter, plus one hundred percent (100%) of the Medicare Part A deductible as defined in Rule 0780-01-58-.09(3)(a) of this Chapter.(c) Standardized Medicare supplement benefit Plan C shall include only the following: The basic (core) benefit as defined in Rule 0780-01-58-.09(2) of this Chapter, plus one hundred percent (100%) of the Medicare Part A deductible, skilled nursing facility care, one hundred percent (100%) of the Medicare Part B deductible, and medically necessary emergency care in a foreign country as defined in Rules 0780-01-58-.09(3)(a), (c), (d), and (f) of this Chapter, respectively.(d) Standardized Medicare supplement benefit Plan D shall include only the following: The basic (core) benefit as defined in Rule 0780-01-58-.09(2) of this Chapter, plus one hundred percent (100%) of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in an foreign country as defined in Rules 0780-01-58-.09(3)(a), (c), and (f) of this Chapter, respectively.(e) Standardized Medicare supplement [regular] Plan F shall include only the following: The basic (core) benefit as defined in Rule 0780-01-58-.09(2) of this Chapter, plus one hundred percent (100%) of the Medicare Part A deductible, the skilled nursing facility care, one hundred percent (100%) of the Medicare Part B deductible, one hundred percent (100%) of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in Rules 0780-01-58-.09(3)(a), (c), (d), (e), and (f), respectively.(f) Standardized Medicare supplement Plan F with High Deductible shall include only the following: one hundred percent (100%) of covered expenses following the payment of the annual deductible set forth in part 2. below. 1. The basic (core) benefit as defined in Rule 0780-01-58-.09(2) of this Chapter, plus one hundred percent (100%) of the Medicare Part A deductible, skilled nursing facility care, one hundred percent (100%) of the Medicare Part B deductible, one hundred percent (100%) of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in Rules 0780-01-58-.09(3)(a), (c), (d), (e), and (f) of this Chapter, respectively.2. The annual deductible in Plan F with High Deductible shall consist of out-of-pocket expenses, other than premiums, for services covered by regular Plan F, and shall be in addition to any other specific benefit deductibles. The basis for the deductible shall be one thousand five hundred dollars ($1,500) and shall be adjusted annually from 1999 by the Secretary of the U.S. Department of Health and Human Services to reflect the change in the Consumer Price Index for all urban consumers for the twelve (12) month period ending with August of the preceding year, and rounded to the nearest multiple of ten dollars ($10).(g) Standardized Medicare supplement benefit Plan G shall include only the following: The basic (core) benefit as defined in Rule 0780-01-58-.09(2) of this Chapter, plus one hundred percent (100%) of the Medicare Part A deductible, skilled nursing facility care, one hundred percent (100%) of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in Rules 0780-01-58-.09(3)(a), (c), (e), and (f) of this Chapter, respectively. Effective January 1, 2020, the standardized benefit plans described in Rule 0780-01-58-.12(1)(d) of this Chapter (Redesignated Plan G High Deductible) may be offered to any individual who was eligible for Medicare prior to January 1, 2020.(h) Standardized Medicare supplement Plan K is mandated by The Medicare Prescription Drug, Improvement and Modernization Act of 2003, and shall include only the following: 1. Part A Hospital Coinsurance, sixty-first (61st) through ninetieth (90th) days: Coverage of one hundred percent (100%) of the Part A hospital coinsurance amount for each day used from the sixty-first (61st) through the ninetieth (90th) day in any Medicare benefit period;2. Part A Hospital Coinsurance, ninety-first (91st) through one hundred fiftieth (150th) days: Coverage of one hundred percent (100%) of the Part A hospital coinsurance amount for each Medicare lifetime inpatient reserve day used from the ninety-first (91st) through the one hundred fiftieth (150th) day in any Medicare benefit period;3. Part A Hospitalization After one hundred fifty (150) days: Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of one hundred percent (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. The provider shall accept the issuer's payment as payment in full and may not bill the insured for any balance;4. Medicare Part A Deductible: Coverage for fifty percent (50%) of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in part 10.;5. Skilled Nursing Facility Care: Coverage for fifty percent (50%) of the coinsurance amount for each day used from the twenty-first (21st) day through the one hundredth (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 part 10.;6. Hospice Care: Coverage for fifty percent (50%) of cost sharing for all Part A Medicare eligible expenses and respite care until the out-of-pocket limitation is met as described in part 10.;7. Blood: Coverage for fifty percent (50%), under Medicare Part A or B, of 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 until the out-of-pocket limitation is met as described in part 10.;8. Part B Cost Sharing: Except for coverage provided in part 9., coverage for fifty percent (50%) 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 part 10.;9. Part B Preventive Services: Coverage of one hundred percent (100%) of the cost sharing for Medicare Part B preventive services after the policyholder pays the Part B deductible; and10. Cost Sharing After Out-of-Pocket Limits: Coverage of one hundred percent (100%) 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 four thousand dollars ($4000) in 2006, indexed each year by the appropriate inflation adjustment specified by the Secretary of the U.S. Department of Health and Human Services.(i) Standardized Medicare supplement Plan L is mandated by The Medicare Prescription Drug, Improvement and Modernization Act of 2003, and shall include only the following: 1. The benefits described in subparagraph (h), parts 1., 2., 3., and 9.;2. The benefit described in subparagraph (h), parts 4., 5., 6., 7., and 8., but substituting seventy-five percent (75%) for fifty percent (50%); and3. The benefit described in subparagraph (h), part 10., but substituting two thousand dollars ($2,000) for four thousand dollars ($4,000).(j) Standardized Medicare supplement Plan M shall include only the following: The basic (core) benefit as defined in Rule 0780-01-58-.09(2) of this Chapter, plus fifty percent (50%) of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in Rules 0780-01-58-.09(3)(b), (c), and (f) of this Chapter, respectively.(k) Standardized Medicare supplement Plan N shall include only the following: The basic (core) benefit as defined in Rule 0780-01-58-.09(2) of this Chapter, plus one hundred percent (100%) of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in Rules 0780-01-58-.09(3)(a), (c), and (f) of this Chapter, respectively, with co-payments in the following amounts:1. the lesser of twenty dollars ($20) or the Medicare Part B coinsurance or co-payment for each covered health care provider office visit, including visits to medical specialists; and2. the lesser of fifty dollars ($50) or the Medicare Part B coinsurance or co-payment for each covered emergency room visit, however, this co-payment shall be waived if the insured is admitted to any hospital and the emergency visit is subsequently covered as a Medicare Part A expense.(6) New or Innovative Benefits: An issuer may, with the prior approval of the commissioner, offer policies or certificates with new or innovative benefits, in addition to the standardized benefits provided in a policy or certificate that otherwise complies with the applicable standards. The new or innovative benefits shall include only benefits that are appropriate to Medicare supplement insurance, are new or innovative, are not otherwise available, and are cost-effective. Approval of new or innovative benefits must not adversely impact the goal of Medicare supplement simplification. New or innovative benefits shall not include an outpatient prescription drug benefit. New or innovative benefits shall not be used to change or reduce benefits, including a change of any cost-sharing provision, in any standardized plan.Tenn. Comp. R. & Regs. 0780-01-58-.11
Original rule filed August 14, 1989; effective September 28, 1989. Repealed and new rule filed November 26, 1990; effective January 10, 1991. Repealed and new rule filed September 16, 1992; effective November 1, 1992. Amendment filed August 15, 1996; effective October 29, 1996. Amendment filed October 25, 1999; effective January 3, 2000. Public necessity rule filed September 1, 2005; effective through February 13, 2006. Public necessity rule filed September 1, 2005; expired on February 13, 2006. On February 14, 2006, reverted to rule in effect on August 31, 2005. Repeal and new rule filed October 13, 2006; effective December 27, 2006. Public necessity rule filed June 30, 2009; effective through December 12, 2009. Emergency rule filed December 9, 2009; effective through June 7, 2010. Amendment filed December 3, 2009; effective March 3, 2010. Administrative changes made to the authority of this chapter due to revisions in the 2016 Tennessee Code Annotated. Amendments filed November 20, 2018; effective 2/18/2019.Authority: T.C.A. §§ 56-1-701; 56-2-301; 56-6-112; 56-6-124(a); 56-7-1401, et seq.; 56-7-1453; 56-7-1454; 56-7-1455; 56-7-1457; 56-7-1501, et seq.; 56-7-1503; 56-7-1504; 56-7-1505; 56-7-1507; and 56-32-118(a); Omnibus Budget Reconciliation Act of 1990, Pub. L. No. 101-508, (1990); Genetic Information Non Discrimination Act, Pub. L. No. 110-233 (2008); Medicare Improvements for Patients and Providers Act, Pub. L. No. 110-275 (2008); and Medicare Access and CHIP Reauthorization Act, Pub. L. No. 114-10 (2015).