W. Va. Code R. § 114-17-6

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

Section 114-17-6 - Required Disclosure Provisions

6.1. Term of coverage. -- Each Medicare Supplement or Limited Benefit Medicare Supplement policy or contract shall include a renewal, continuation or nonrenewal provision. The language or specifications of such provision must be consistent with the type of contract to be issued. Such provision shall be appropriately captioned, shall appear on the first page of the policy or contract, and shall clearly state the duration, where limited, of renewability and the duration of the term of coverage for which the policy or contract is issued and for which it may be renewed.

6.2. Payment of benefit standards. -- A Medicare Supplement or Limited Benefit Medicare Supplement policy or contract which provides for the payment of benefits based on standards described as "Usual and Customary," "Reasonable and Customary," or words of similar import shall include a definition of such terms and an explanation of such terms in its accompanying outline of coverage.

6.3. Preexisting condition limitations. -- If a Medicare Supplement or Limited Benefit Medicare Supplement policy or contract contains any limitations with respect to preexisting conditions, such limitations must appear as a separate paragraph of the policy or contract and be labeled as "Preexisting Condition Limitations."

6.4. Right to return. -- Medicare Supplement or Limited Benefit Medicare Supplement policies, certificates or contracts issued to persons eligible for Medicare by reason of age, other than those issued pursuant to direct response solicitation, shall have a notice prominently printed on the first page of the policy, certificate or contract, attached thereto stating in substance that the insured person shall have the right to return the policy, certificate or contract within ten (10) days of its delivery and to have the premium refunded if, after examination of the policy, certificate or contract, the insured person is not satisfied by any reason. Policies, certificates or contracts issued pursuant to a direct response solicitation to persons eligible for Medicare by reason of age shall have a notice prominently printed on the first page or attached thereto stating in substance that the policyholder, certificate holder or contract holder shall have the right to return the policy, certificate or contract within thirty (30) days of its delivery and to have the premium refunded if after examination the insured person is not satisfied for any reason.

6.5. Buyer's guide. -- Insurers issuing individual or group policies or contracts sold primarily to persons eligible for Medicare by reason of age, which provide hospital or medical expense coverage on an expense incurred or indemnity basis, other than incidentally, shall provide to the policyholder a Medicare Supplement "Buyer's Guide": Provided, That such "Buyer's Guide" shall, at the time of issuance, reflect current Medicare benefits, copayments and deductibles. Delivery of the Buyer's Guide shall be made whether or not such policy or contract qualifies as a Medicare Supplement or Limited Benefit Medicare Supplement policy as defined in this regulation. Except in the case of direct response insurers, delivery of the Buyer's Guide shall be made at the time of application, and acknowledgment of receipt of the Buyer's Guide shall be provided to the insurer. Direct response insurers shall deliver the Buyer's Guide upon request but not later than at the time the policy is delivered.

6.6. Outline of coverage requirements for Medicare Supplement and Limited Benefit Medicare Supplement policies, certificates or contracts:

(a)

(1) Insurers issuing Medicare Supplement or Limited Benefit Medicare Supplement policies, certificates or contracts shall deliver an outline of coverage which meets the requirements of this section to the applicant at the time application is made and, except for the direct response policy, secure an acknowledgment of receipt from the applicant; and

(2) If an outline of coverage was delivered at the time of application and the individual policy or contract is issued on a basis which would require revision of the outline, a substitute outline of coverage properly describing the policy or contract shall accompany such policy or contract when it is delivered and shall contain the following statement, in no less than twelve (12) point type, immediately above the company name: "NOTICE: Read this outline of coverage carefully. It is not identical to the outline of coverage provided upon application and the coverage originally applied for has been issued."

(b) An outline of coverage, in the form prescribed below, shall be issued in connection with the issuance of Medicare Supplement or Limited Benefit Medicare Supplement policies or contracts. The items included in the outline of coverage must appear in the sequence prescribed.

(COMPANY NAME AND ADDRESS)

OUTLINE OF MEDICARE

SUPPLEMENT OR LIMITED BENEFIT

MEDICARE

SUPPLEMENT COVERAGE

(1) Read Your Policy Carefully. -- This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY CAREFULLY!

(2) Medicare Supplement Coverage. -- Policies of this category are designed to supplement Medicare by covering some hospital, medical and surgical services which are partially covered by Medicare. Coverage is provided for hospital in-patient charges and some physician charges, subject to any deductibles and copayment provisions which may be in addition to those provided by Medicare, and subject to other limitations which may be set forth in the policy. The policy does not provide benefits for custodial care such as help in walking, getting in and out of bed, eating, dressing, bathing and taking medicine (delete if such coverage is provided).

(3)

(a) (Where agent used):

Neither (insert company's name) nor its agents are connected with Medicare.

(b) (For direct responses):

(Insert company's name) is not connected with Medicare.

(4) A brief summary of the major benefit gaps in Medicare Parts A & B with a parallel description of supplemental benefits, including dollar amounts, provided by the Medicare Supplement coverage in the following order: (See Table 114-17A found at the end of this regulation.)

(5) Statement that the policy does or does not cover the following:

(A) Private duty nursing;

(B) Skilled nursing home care costs (beyond what is covered by Medicare);

(C) Custodial nursing home care costs;

(D) Intermediate nursing home care costs;

(E) Home health care above number of visits covered by Medicare;

(F) Physician charges (above Medicare's reasonable charge);

(G) Drugs (other than prescription drugs furnished during a hospital or skilled nursing facility stay);

(H) Care received outside of United States of America;

(I) Dental care or dentures, checkups, routine immunizations, cosmetic surgery, routine foot care, examinations for the cost of eyeglasses or hearing aids.

(6) Include here a description of any policy provisions which exclude, eliminate, resist, reduce, limit, delay or in any other manner operate to qualify payments of the benefits described in Subdivision (4) above, including conspicuous statements:

(A) That the chart summarizing Medicare benefits only briefly describes such benefits;

(B) That the Health Care Financing Administration or its Medicare publications should be consulted for further details and limitations.

(7) Include here a description of policy provisions or continuation of coverage, including any reservation or rights to change premium.

(8) The amount of premium for this policy.

("Certificate" for "Policy" where appropriate.)

W. Va. Code R. § 114-17-6