W. Va. Code R. § 114-17-4

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 114-17-4 - Minimum Standards for Medicare Supplement and Limited Benefit Medicare Supplement Policies and Contracts

No Medicare Supplement or Limited Benefit Medicare Supplement policy or contract shall be delivered or issued for delivery in this State which does not meet the requirements of this section. These are minimum standards and do not preclude the inclusion of other provisions or benefits in addition to, and which are not inconsistent with, these standards.

4.1. General policy provisions.

(a) Limitations based on preexisting conditions shall not exclude coverage for more than six (6) months after the effective date of coverage of the insured person for a condition for which medical advice was given or treatment was recommended by or received from a physician within six (6) months before the effective date of the coverage of an insured person.

(b) Coverage shall not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents.

(c) Coverage shall provide that benefits designed to cover cost sharing amounts under Medicare will be proportionally changed automatically to coincide with any changes in the applicable Medicare deductible amount and copayment percentage factors. Premiums may be changed to correspond with such changes, subject to prior approval by the Commissioner or the filed rates may include incremental increases which anticipate changes in Medicare coverage.

(d) The terms "Medicare Supplement," "Medigap" and words of similar import shall not be used in any manner to describe a policy or contract unless the policy or contract is issued in compliance with this regulation.

4.2. Minimum benefit standards for Medicare Supplement coverage. -- Medicare Supplement policies or contracts shall provide at least the following benefits to an insured person:

(a) Coverage of the initial Part A Medicare deductible as established from time to time by the Social Security Administration;

(b) Coverage of Part A Medicare eligible expenses for hospitalization to the extent not covered by Medicare from the sixty-first day through the ninetieth day in any Medicare benefit period;

(c) Coverage of Part A Medicare eligible expenses for hospitalization to the extent not covered by Medicare from the ninety-first day through the one hundred fiftieth day in any Medicare benefit period;

(d) Upon exhaustion of all Medicare hospital in-patient coverage, including the lifetime reserve days, coverage of ninety percent (90%) of all Medicare Part A eligible expenses for hospitalization not covered by Medicare, subject to a lifetime maximum benefit of an additional three hundred sixty-five (365) days;

(e) Coverage of Part A Medicare eligible expenses for post-hospitalization skilled nursing facility care to the extent not covered by Medicare from the twenty-first day to the eightieth day in any Medicare benefit period;

(f) Coverage of Part A Medicare eligible expenses for any number of pints of blood to the extent not covered by Medicare in any Medicare benefit period;

(g) Coverage of the initial Part B Medicare deductible as established from time to time by the Social Security Administration; and

(h) Coverage of twenty percent (20%) of the amount of Medicare eligible expenses under Part B regardless of hospital confinement, subject to a maximum calendar year out-of-pocket deductible of two hundred dollars ($200) of such expenses and to a maximum of at least five thousand dollars ($5,000) per calendar year.

4.3. Minimum benefit standards for limited benefit Medicare supplement coverage. -- Limited Benefit Medicare Supplement policies or contracts shall provide at least the following benefits to an insured person:

(a) The initial Part A Medicare deductible as established from time to time by the Social Security Administration;

(b) Coverage of Part A Medicare eligible expenses incurred as daily hospital charges during use of Medicare's lifetime hospital in-patient reserve days;

(c) Coverage of Part A Medicare eligible expenses for hospitalization to the extent not covered by Medicare from the sixty-first day through the ninetieth day in any Medicare benefit period;

(d) Upon exhaustion of all Medicare hospital in-patient coverage including the lifetime reserve days, coverage of ninety per cent (90%) of all Medicare Part A eligible expenses for hospitalization not covered by Medicare subject to a lifetime maximum benefit of an additional three hundred sixty-five (365) days; and

(e) Coverage of twenty percent (20%) of the amount of Medicare eligible expenses under Part B regardless of hospital confinement, subject to a maximum calendar year out-of-pocket deductible of two hundred dollars ($200) of such expenses and to a maximum of at least five thousand dollars ($5,000) per calendar year.

W. Va. Code R. § 114-17-4