Source: http://www.tdi.texas.gov/rules/2004/1115-059.html
Timestamp: 2018-03-20 02:00:12
Document Index: 10360990

Matched Legal Cases: ['§3', '§3', '§3', '§3', '§3', '§3', '§3', '§3', '§3', '§3', '§3', '§3', '§3', '§3', '§3', '§3', '§3', '§3', '§3', '§3', '§3', '§3', '§3', '§3', '§3', '§3', '§3', '§2', '§36', '§2', '§1395', '§10', '§1395', '§3', '§21', '§ 300', '§1876', '§1395', '§1833', '§1395', '§422', '§1395', '§3', '§3', '§3', '§3', '§3', '§3', '§3', '§3', '§3', '§3', '§3', '§3', '§3', '§3', '§3', '§3', '§3', '§3']

28 TAC §§3.3303 ­ 3.3309, §3.3312, §3.3320, §3.3322, §3.3324, and §3.3325
The Texas Department of Insurance proposes amendments to §§3.3303 ­ 3.3309, §3.3312, §3.3320, §3.3322, §3.3324, and §3.3325 concerning minimum standards for Medicare supplement policies. These amendments are necessary to conform Texas law to the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), as well as to make persons losing eligibility for health benefits under Medicaid eligible for guaranteed issuance of certain Medicare supplement plans. After December 31, 2005 , MMA prohibits issuers of Medicare supplement policies from renewing outpatient prescription drug benefits for both prestandardized and standardized Medicare supplement policyholders who enroll in Medicare Part D.
Proposed §3.3303 revises definitions to conform to the MMA, as does proposed §3.3304. Proposed §3.3305 alters requirements for issuance and renewability of plans including an outpatient prescription drug benefit to conform to the MMA. Proposed §3.3306 revises minimum benefit standards to conform to the MMA and the phase-out of the existing forms of outpatient prescription drug benefits; revises payment standards for Medicare Part A expenses; and defines the benefits included in new Plans K and L. Proposed §3.3307 amends loss ratio standards for HMOs to conform to the MMA. Proposed §3.3308 requires issuers to comply with notice requirements of the MMA. Proposed §3.3309 revises standards for applications in accordance with the MMA. Proposed §3.3312 changes standards for guaranteed issuance to conform to the MMA and makes individuals losing eligibility for health benefits under Medicaid eligible for guaranteed issuance of certain Medicare supplement plans. Proposed §3.3320 prohibits issuing Medicare supplement coverage to an individual enrolled in Medicare Part C unless the effective date is after the termination of the Part C coverage. Proposed §3.3322 makes changes to filing requirements to conform to the MMA. Proposed §3.3324 adds §3.3312 to the list of exceptions to an issuer´s authority to apply a preexisting condition provision. Proposed §3.3325 addresses the effect of out-of-network expenses on out-of-pocket annual limits in Plans K and L and makes other changes to conform to the MMA.
Throughout the sections the department has made minor changes to correct form and grammar, make clarifications, correct citations and update examples and references to form numbers.
Kim Stokes, Senior Associate Commissioner for the Life, Health & Licensing Program, has determined that for each year of the first five years the proposed sections will be in effect, there will be no fiscal impact to state and local governments as a result of the enforcement or administration of the rule. There will be no measurable effect on local employment or the local economy as a result of the proposal.
Ms. Stokes has determined that for each year of the first five years the sections are in effect, the public benefits anticipated as a result of the proposed sections will be Texas´s continued compliance with federal standards and requirements relating to regulation of Medicare supplement coverage, as well as expansion of access to Medicare supplement coverage for those persons losing eligibility for health coverage under Medicaid. With the exception of proposed §3.3312(b)(8), the probable economic cost to persons required to comply with the sections is due to the MMA and not the result of this proposal. There is no cost to persons required to comply with §3.3312(b)(8), since an issuer will charge an adequate premium to any person entitled to guaranteed issuance under that provision. As there are no costs attributable to the proposal, there is no effect on small and micro businesses.
Even if this proposed change had a cost, there would be no adverse economic effect on small businesses, as the cost for each hour of labor would be the same for small or micro-businesses and all other businesses. Regardless of the fiscal effect, the department does not believe it legal or feasible to waive the requirements of these rules for small businesses or micro-businesses, as to do so would impair the uniform regulation of Medicare supplement coverage.
To be considered, written comments on the proposal must be submitted no later than 5:00 p.m. on December 27, 2004 to Gene C. Jarmon, General Counsel and Chief Clerk, Mail Code 113-2A, Texas Department of Insurance, P. O. Box 149104, Austin, Texas 78714-9104. An additional copy of the comment must be simultaneously submitted to Bill Bingham, Deputy for Regulatory Matters, Mail Code 107-2A, Texas Department of Insurance, P.O. Box 149104, Austin, Texas 78714-9104. The department will consider the adoption of the proposed amendments in a public hearing under Docket Number 2609, scheduled for 9:30 a.m. , on January 13, 2005 , in Room 100 of the William P. Hobby, Jr. State Office Building, 333 Guadalupe Street , Austin , Texas .
The amendments are proposed under the Insurance Code Article 3.74, §§2(f) and 10 and §36.001. Article 3.74, §2(f) provides that the department´s rules must include requirements that are at least equal to those required by federal law, rules, and standards, including 42 U.S.C. §1395ss. Article 3.74, §10 provides that the department shall adopt rules in accordance with federal law applicable to the regulation of Medicare supplement insurance coverage that are necessary for the state to obtain or retain certification as a state with an approved regulatory program under 42 U.S.C. §1395ss, as well as any other reasonable rules that are necessary and proper to carry out this article. Section 36.001 provides that the Commissioner of Insurance may adopt any rules necessary and appropriate to implement the powers and duties of the Texas Department of Insurance under the Insurance Code and other laws of this state.
The following article is affected by this proposal: Insurance Code Article 3.74
§3.3303. Definitions. The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.
(2) Bankruptcy--The situation that occurs when a Medicare Advantage [ Medicare+Choice ] organization that is not an issuer has filed, or has had filed against it, a petition for declaration of bankruptcy and has ceased doing business in this state.
(3) ­ (4) (No change.)
(5) Creditable coverage--Any coverage of an individual as defined in [ ( ]§21.1101 of this title (relating to Definitions).
(7) Health Maintenance Organization (HMO)--An entity as defined in 42 U.S.C. § 300e(a).
(8) - (9) (No change.)
(10) Medicaid-Grants to States for Medical Assistance Programs, Title XIX of the Social Security Act Amendments of 1965 as Then Constituted or Later Amended.
(11) [ (10) ] Medicare--The Health Insurance for the Aged Act, Title XVIII of the Social Security Act Amendments of 1965 as Then Constituted or Later Amended.
(12) [ (11) ] Medicare Advantage [ Medicare+Choice ] organization--An entity as defined in 42 U.S.C. § [ ( ]1395w-28(a)(1).
(13) [ (12) ] Medicare Advantage [ Medicare+Choice ] plan--A plan of coverage for health benefits under Medicare Part C as defined in 42 U.S.C. § [ ( ]1395w-28(b)(1), and includes:
(A) coordinated care plans which provide health services, including but not limited to health maintenance organization plans (with or without a point-of-service option), plans offered by provider-sponsored organizations, and preferred provider organization plans;
(B) medical savings account plans coupled with a contribution into a Medicare Advantage [ Medicare+Choice ] medical savings account; and
(C) Medicare Advantage [ Medicare+Choice ] private fee-for-service plans.
(14) [ (13) ] Medicare Advantage [ Medicare+Choice ] private fee-for-service plan--An entity as defined in 42 U.S.C. § [ ( ]1395w-28(b)(2).
(15) MMA--The Medicare Prescription Drug, Improvement, and Modernization Act of 2003.
(16) [ (14) ] Medicare Select policy or Medicare Select certificate--A Medicare supplement policy or certificate, respectively, that contains restricted network provisions.
(17) [ (15) ] Medicare supplement policy--A group or individual policy of accident and sickness insurance or a subscriber contract of a hospital service corporation subject to the Insurance Code, Chapter 20, or, to the extent required by federal law, an evidence of coverage issued by a health maintenance organization subject to the Texas Health Maintenance Organization Act, which policy, subscriber contract, or such evidence of coverage is advertised, marketed, or designed primarily as a supplement to reimbursements under Medicare for the hospital, medical, or surgical expenses of persons eligible for Medicare. The term does not include:
(A) a policy, contract, subscriber contract, or evidence of coverage of one or more employers or labor organizations, or of the trustees of a fund established by one or more employers or labor organizations, or combination thereof, for employees or former employees, or combination thereof, or for members or former members, or combination thereof, of the labor organizations;
(B) a policy or health care benefit plan including a policy or contract of group insurance or group contract of a hospital service corporation subject to the Insurance Code, Chapter 20, or group evidence of coverage issued by a health maintenance organization subject to the Texas Health Maintenance Organization Act, when such policy or plan is not marketed or held to be a Medicare supplement policy or benefit plan; or
(C) an individual or group evidence of coverage issued pursuant to a contract under the Federal Social Security Act, §1876 (42 USC [ United States Code ] §§1395, et seq . ) by a health maintenance organization subject to the Texas Health Maintenance Organization Act (Texas Insurance Code, Chapters [ Chapter ] 20A and 843 ) ;
(D) a Medicare Advantage plan established under Medicare Part C;
(E) an Outpatient Prescription Drug plan established under Medicare Part D; or
(F) a Health Care Prepayment Plan (HCPP) that provides benefits pursuant to an agreement under §1833(a)(1)(A) of the Federal Social Security Act (42 USC §§1395, et seq.)
(18) [ (16) ] Point-of-service--A benefit option as defined in 42 C.F.R. §422.2 [ (422.2 ].
(19) [ (17) ] Provider-Sponsored organization--An entity as defined in 42 U.S.C. §1395w-25(d)(1) [ (1395w-25(d)(1) ].
(20) [ (18) ] Qualified actuary--An actuary who is a member of either the Society of Actuaries or the American Academy of Actuaries.
(21) [ (19) ] Secretary--The Secretary of the United States Department of Health and Human Services.
§3.3304. Policy Definitions and Terms. No insurance policy, subscriber contract, certificate, or evidence of coverage may be advertised, solicited, or issued for delivery in this state as a Medicare supplement policy unless such policy, subscriber contract, certificate, or evidence of coverage contains definitions or terms which conform to the requirements of this section.
(4) "Health Care Expenses" are , for purposes of §3.3307 of this chapter (relating to Loss Ratio Standards and Refund or Credit of Premiums), those expenses of health maintenance organizations associated with the delivery of health care services and analogous to incurred losses of insurers. [ Expenses shall not include: ]
[ (A) home office and overhead costs; ]
[ (B) advertising costs; ]
[ (C) commissions and other acquisition costs; ]
[ (D) taxes; ]
[ (E) capital costs; ]
[ (F) administrative costs; and ]
[ (G) claims processing costs. ]
(8) "Medicare Eligible Expenses" are health care expenses of the kinds covered by Medicare Parts A and B , to the extent recognized as reasonable and medically necessary by Medicare.
(9) - (11) (No change.)
§3.3305. Policy Provisions.
(d) Subject to §3.3306(1)(D) and (E) of this chapter (relating to Minimum Benefit Standards), a Medicare supplement policy with benefits for outpatient prescription drugs in existence prior to January 1, 2006, shall be renewed for current policyholders who do not enroll in Part D at the option of the policyholder.
(e) A Medicare supplement policy with benefits for outpatient prescription drugs shall not be issued after December 31, 2005 .
(f) After December 31, 2005 , a Medicare supplement policy with benefits for outpatient prescription drugs may not be renewed after the policyholder enrolls in Medicare Part D unless:
(1) the policy is modified to eliminate outpatient prescription coverage for expenses of outpatient prescription drugs incurred after the effective date of the individual's coverage under a Part D plan; and
(E) Each Medicare supplement policy shall be guaranteed renewable and shall comply with the provisions of clauses (i) - (v) [ (iv) ] of this subparagraph.
(i) - (iv) (No change.)
(v) If a Medicare supplement policy eliminates an outpatient prescription drug benefit as a result of requirements imposed by the MMA, the modified policy shall be deemed to satisfy the guaranteed renewal requirements of this paragraph.
(F) Termination of a Medicare supplement policy shall be without prejudice to any continuous loss which commenced while the policy was in force, but the extension of benefits beyond the period during which the policy was in force may be predicated 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.
(II) resumption of coverage which is substantially equivalent to coverage in effect before the date of such suspension . If the suspended Medicare supplement policy provided coverage for outpatient prescription drugs, reinstitution of the policy for Medicare Part D enrollees shall be without coverage for outpatient prescription drugs and shall otherwise provide substantially equivalent coverage to the coverage in effect before the date of the suspension ; and
(H) If a Medicare supplement policy eliminates an outpatient prescription drug benefit as a result of requirements imposed by the MMA, the modified policy shall be deemed to satisfy the guaranteed renewal requirements of this paragraph.
(2) Standards for the basic (core) benefits common to [ all ] benefit plans A - J . Every issuer shall make available a policy or certificate including only the basic "core" package of benefits described in subparagraphs (A) - (E) of this paragraph to each prospective insured. An issuer may make available to prospective insureds any of the other Medicare supplement insurance benefit plans in addition to the basic core package, but not in lieu of it. The basic core benefits shall consist of the following:
(C) upon exhaustion of all 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 rate, [ diagnostic related group (DRG) day outlier per diem ] 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 ;
(F) Basic Outpatient Prescription Drug Benefit--Coverage for 50% 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.
(G) Extended Outpatient Prescription Drug Benefit--Coverage for 50% 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.
(I) Preventive Medical Care Benefit or Services--Coverage for the preventive health services described in clauses (i) and (ii) [ (iv) ] of this subparagraph. Coverage for preventive medical care benefits or services shall be for the actual charges up to 100% 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 (AMA CPT) codes, to a maximum of $120 annually under this benefit. This benefit shall not include payment for any procedure covered by Medicare:
(ii) [ any one or a combination of the following ] preventive screening tests or preventive services, the selection and frequency of which are [ is ] determined to be [ considered ] medically appropriate by the attending physician [ : ]
[ (I) digital rectal examination; ]
[ (II) dipstick urinalysis for hematuria, bacteriuria, and proteinuria; ]
[ (III) pure tone (air only) hearing screening test, administered or ordered by a physician; ]
[ (IV) serum cholesterol screening (every five years); ]
[ (V) thyroid function test; or ]
[ (VI) diabetes screening; ]
[ (iii) tetanus and diphtheria booster (every 10 years); ]
[ (iv) any other tests or preventive measures determined appropriate by the attending physician ].
(K) New or Innovative Benefits--Any benefit which an issuer may, with the prior approval of the commissioner, offer in addition to the benefits provided in a policy or certificate that otherwise complies with the applicable standards. The 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.
(5) Make-up of Benefit Plans. Subparagraphs (A) - (N) [ (L) ] of this paragraph set out the composition of benefit plans. Each benefit plan shall meet the requirements of this subchapter.
(I) Standardized Medicare Supplement Benefit Plan "H." Medicare supplement benefit Plan "H" shall include only the Core Benefit as defined in paragraph (2) of this section, plus the Medicare Part A Deductible, Skilled Nursing Facility Care, Basic Prescription Drug Benefit and Medically Necessary Emergency Care in a Foreign Country as defined in paragraph (3) of this section. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005.
(J) Standardized Medicare Supplement Benefit Plan "I." Medicare supplement benefit Plan "I" shall include only the Core Benefit as defined in paragraph (2) of this section, plus the Medicare Part A Deductible, Skilled Nursing Facility Care, One Hundred Percent (100%) of the Medicare Part B Excess Charges, Basic Prescription Drug Benefit, Medically Necessary Emergency Care in a Foreign Country and At-Home Recovery Benefit as defined in paragraph (3) of this section. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005.
(K) Standardized Medicare Supplement Benefit Plan "J." Medicare supplement benefit Plan "J" shall include only the Core Benefit as defined in paragraph (2) of this section, plus the Medicare Part A Deductible, Skilled Nursing Facility Care, Medicare Part B Deductible, One Hundred Percent of the Medicare Part B Excess Charges, Extended Prescription Drug Benefit, Medically Necessary Emergency Care in a Foreign Country, Preventive Medical Care and At-Home Recovery Benefit as defined in paragraph (3) of this section. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005.
(L) Standardized Medicare Supplement Benefit High Deductible Plan "J." Medicare supplement benefit high deductible Plan "J" shall include only the following: 100% 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 (2) of this section, plus the Medicare Part A Deductible, Skilled Nursing Facility Care, Medicare Part B Deductible, 100% 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 paragraph (3) 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 $1500 for 1998 and 1999, and shall be based on the calendar year. It shall be adjusted annually thereafter by the Secretary to reflect the change in the Consumer Price Index for all urban consumers for the twelve-month period ending with August of the preceding year, and rounded to the nearest multiple of $10. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005.
(M) Standardized Medicare supplement benefit Plan "K" shall include only the following:
(i) Coverage of 100% 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% 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% of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system 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) Medicare Part A Deductible: Coverage for 50% of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in clause (x) of this subparagraph ;
(v) Skilled Nursing Facility Care: Coverage for 50% 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 clause (x) of this subparagraph;
(vi) Hospice Care: Coverage for 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 clause (x) of this subparagraph;
(vii) Coverage for 50%, 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 clause (x) of this subparagraph;
(viii) Except for coverage provided in clause (ix) of this subparagraph, coverage for 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 clause (x) of this subparagraph;
(ix) Coverage of 100% of the cost sharing for Medicare Part B preventive services after the policyholder pays the Part B deductible; and
(x) Coverage of 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 $4000 in calendar year 2006, indexed each year by the appropriate inflation adjustment specified by the Secretary.
(N) Standardized Medicare supplement benefit Plan "L" shall include only the following:
(i) The benefits described in subparagraph (M)(i), (ii), (iii) and (ix) of this paragraph;
(ii) The benefits described in subparagraph (M)(iv), (v), (vi), (vii) and (viii) of this paragraph, but substituting 75% for 50%; and
(iii) The benefit described in subparagraph (M)(x) of this paragraph, but substituting $2000 for $4000.
§3.3307. Loss Ratio Standards and Refund or Credit of Premiums.
(b) Health maintenance organization loss ratio standard. A health maintenance organization loss ratio, where coverage is provided on a service rather than reimbursement basis, shall be calculated on the basis of incurred claims experience or incurred health care expenses and earned premiums for the period and in accordance with accepted actuarial principles and practices. Incurred health care expenses where coverage is provided by a health maintenance organization shall not include:
(c) Calendar year experience loss ratio standard. For the most recent calendar year, the ratio of incurred losses to earned premiums for all policies or certificates which have been in force for three years or more, as of December 31st of the most recent year, shall be equal to or greater than:
(1) at least 75% in the case of group policies; and
(2) at least 65% in the case of individual policies.
(d) [ (c) ] Filing of rates and rating schedules. All filings of rates and rating schedules shall demonstrate that expected claims in relation to premiums comply with the requirements of this section when combined with actual experience to date. Filings of rate revisions shall also demonstrate that the anticipated loss ratio over the entire future period for which the revised rates are computed to provide coverage can be expected to meet the appropriate loss ratio standards. For individual or group policies issued prior to March 1, 1992 , the provisions of paragraph (3) of this subsection must be met with respect to expected claims in relation to premiums. For purposes of submitting a rate filing under this section, policy forms, whether for open or closed blocks of business, providing for similar benefits shall be combined. However, for purposes of the required combination set out in this section, issuers may distinguish between policy forms providing for similar benefits for individuals 65 years of age or over and policy forms providing for similar benefits for individuals under age 65. Once policy forms have been combined, they remain so for all rating purposes. When forms have been so combined, a rate revision request shall not differentiate between the experience of the individual forms. Where significant inconsistencies between rate levels exist between forms providing similar benefits, some deviation in rate revision shall be allowed to reduce the significant inconsistencies.
(1) Each Medicare supplement policy or certificate form shall be accompanied, upon submission for approval, by an actuarial memorandum. Such memorandum shall be prepared and signed by a qualified actuary in accordance with generally accepted actuarial principles and practices, and shall contain the information listed in the following subparagraphs:
(A) the form number that the actuarial memorandum addresses;
(B) a brief description of benefits provided;
(C) a schedule of rates to be used;
(D) a complete explanation of the rating process, including assumptions, claims data, methodology, and formulae used in developing the gross premium rates;
(E) a statement of what experience base will be used in future rate adjustments;
(F) a certification that the anticipated aggregate loss ratio is at least 65% (for individual coverage) or at least 75% (for group coverage), which certification should include a statement of the period over which the aggregate loss ratio is expected to be realized;
(G) a table of anticipated loss ratio experience for representative issue ages for each year from issue over the period of time over which the aggregate loss ratio is to be realized; and
(H) a certification that the premiums are reasonable in relation to the benefits provided.
(2) Subsequent rate adjustment filings, except for those rates [ rate ] filed solely due to a change in the Part A calendar year deductible, shall also provide an actuarial memorandum, prepared by a qualified actuary, in accordance with generally accepted actuarial principles and practices, which memorandum shall contain the information in the following subparagraphs.
(A) The form number addressed by the actuarial memorandum shall be included.
(B) A brief description of benefits provided shall be included.
(C) A schedule of rates before and after the rate change shall be included.
(D) A statement of the reason and basis for the rate change shall be included.
(E) A demonstration and certification by the qualified actuary shall be included to show that the past plus future expected experience after the rate change will result in an aggregate loss ratio equal to, or greater than, the required minimum aggregate loss ratio.
(i) This rate change and demonstration shall be based on the experience of the named form in Texas only, if that experience is fully credible, as set out in paragraph (3) of this subsection.
(ii) The rate change and demonstration shall be based on experience of the named form nationwide, with credibility factors as set out in paragraph (3) of this subsection applied, if the named form is used nationwide and the Texas experience is not fully credible.
(iii) The rate change and demonstration shall be based on experience of the named form in Texas only, with credibility factors as set out in paragraph (3) of this subsection applied, if the named form is used in Texas only and the Texas experience is not fully credible.
(F) For policies or certificates in force less than three years, a demonstration shall be included to show that the third-year loss ratio is expected to be equal to, or greater than, the applicable percentage.
(G) A certification by the qualified actuary that the resulting premiums are reasonable in relation to the benefits provided shall be included.
(3) For purposes of this subsection, if a group or individual policy form has 2,000 or more policies in force, then full credibility (100%) shall be given to the experience. If fewer than 500 policies are in force, then no credibility (0%) shall be given to the experience. The principle of linear interpolation shall be used for in-force numbers between 500 and 2,000. For group policy forms, the reference in this paragraph to the number of in-force policies means the number of in-force certificates under group policies. For purposes of this section, "in force" means either the average number of policies in force for the experience period used to support the need for a rate revision, or the number of policies in force as of the ending date of the experience period used to support the need for a rate revision. Once an issuer makes a decision as to which definition it will apply to a particular policy form, such decision is irrevocable. An issuer may submit specific alternate credibility standards to the department for consideration. In order for an alternate standard of credibility to be acceptable for application, the issuer must demonstrate that the standards are based on sound actuarial principles, and that the resulting loss ratios are in substantial compliance with the requirements of subsections (a) , (b) and (c) [ (b) ] of this section.
(4) For individual policies issued prior to March 1, 1992 , the expected claims in relation to premiums shall meet:
(A) the originally-filed anticipated loss ratio when combined with the actual experience since inception;
(B) a loss ratio of at least 65% when combined with actual experience beginning with June 1, 1996 to date; and
(C) a loss ratio of at least 65% over the entire future period for which the rates are computed to provide coverage.
(e) [ (d) ] Annual filing of premium rates required. Every issuer of Medicare supplement policies and certificates issued before or after March 1, 1992 in this state shall file annually its rates, rating schedule, and supporting documentation, including ratios of incurred losses to earned premiums for the most recent calendar year broken down by calendar year of issue or by policy duration, for purposes of demonstrating that the issuer is in compliance with the loss ratio standards, and for approval by the Department in accordance with the filing requirements of this section and the requirements of §3.3323 of this title (relating to Increases to Premium Rates). The supporting documentation shall also demonstrate in accordance with actuarial standards of practice using reasonable assumptions that the appropriate loss ratio standards can be expected to be met over the entire period for which rates are computed. Such demonstration shall exclude active life reserves. An expected third-year loss ratio which is greater than or equal to the applicable percentage shall be demonstrated for policies or certificates in force less than three years. The annual filing requirements in this subsection shall be as follows:
(1) the NAIC Medicare supplement experience exhibit which summarizes the experience of each individual form with business in force in Texas ;
(2) the NAIC Medicare supplement experience exhibit which summarizes the experience of each group form with business in force in Texas ;
(3) rates and rating schedules for each form with business in force in Texas ;
(4) a certification by the qualified actuary that the policies or certificates in force less than three years are anticipated to produce a third-year loss ratio which is greater than or equal to the applicable loss ratio percentage; and
(5) a certification by the qualified actuary that the expected losses in relation to premiums over the entire period for which the policy is rated comply with the required minimum aggregate loss ratio standard.
(f) [ (e) ] Refund or credit calculation. An issuer shall collect and file with the commissioner by May 31 of each year the data contained in the "Medicare Supplement Refund Calculation Form," published as Figure 1 to this section, for each type in a standard Medicare supplement benefit plan. This form is published by the Texas Department of Insurance and copies of this form are available from the Life/Health Group, Mail Code 106-1A of the Texas Department of Insurance, P.O. Box 149104 , Austin , Texas 78714-9104 .
(1) If on the basis of the experience as reported the benchmark ratio since inception (ratio 1) exceeds the adjusted experience ratio since inception (ratio 3), then a refund or credit calculation is required. The refund calculation shall be done on a statewide basis for each type in a standard Medicare supplement benefit plan. For purposes of the refund or credit calculation, experience on policies issued within the reporting year shall be excluded.
(2) A refund or credit shall be made only when the benchmark loss ratio exceeds the adjusted experience loss ratio and the amount to be refunded or credited exceeds a de minimis level. The refund shall include interest from the end of the calendar year to the date of the refund or credit at a rate specified by the secretary of health and human services, but in no event shall it be less than the average rate of interest for 13-week treasury notes. A refund or credit against premiums due shall be made by September 30 following the experience year upon which the refund or credit is based.
(3) For an individual or group policy or certificate issued prior to March 1, 1992, the issuer, for purposes of complying with this subsection, shall make the refund or credit calculation separately for all individual policies combined and all group policies combined for experience after June 1, 1996. [ The first such report shall be due by May 31, 1998 . ]
Figure: 28 TAC §3.3307(f)(3) [§3.3307(e)(3)]
FOR CALENDAR YEAR _________
TYPE [1] __________________________SMSBP [2] ____________________________
For the State of _____________________________________________________
NAIC Group Code_______________NAIC Company Code___________________
Person Completing This Exhibit_________________________________________
Title_________________________ Telephone_____________________________
Premium [3] (II)
Claims [4]
a. Total (all policy years) _______ _______
b. Current year's issues [5] _______ _______
c. Net (for reporting purposes) _______ _______
(line 1a - line 1b)
2. Past Year's Experience
(all policy years) _______ _______
(line 1c + line 2) _______ _______
4. Refunds Last Year (excluding interest) __________________
5. Refunds From All Previous Reporting Years
(excluding interest) __________________
6. Refunds Since Inception (excluding interest) __________________
(line 4 + line 5)
(Ratio 1 from worksheet) __________________
TYPE [6] ________________________SMSBP [7] _________________________________
8. Experienced Ratio Since Inception (Ratio 2)
(line 3 col. II) / (line 3 col. I - line 6) _____________________
9. Life Years Exposed Since Inception _____________________
If (line 8 < line 7) AND (line 9 > 499), proceed; otherwise stop.
10. Tolerance Permitted (obtained from credibility table) _____________________
Life Years Exposed Since Inception
If less than 500, no credibility.
11. Adjustment to Incurred Claims for Credibility (Ratio 3) _____________________
(line 8 + line 10)
If line 11 > line 7, a refund/credit is not required, otherwise proceed.
12. Adjusted Incurred Claims
(line 3, col. 1 - line 6) x (line 11) _____________________
Type [8] ________________________SMSBP [9] _________________________________
[line 3, col. I - line 6 - (line 12/line 7)] ___________________
I certify that the above information and calculations are true and accurate to the best of my knowledge and believe.
Name - Please Print or Type
REPORTING FORM FOR THE CALCULATION OF BENCHMARK
RATIO SINCE INCEPTION FOR INDIVIDUAL POLICIES
TYPE [10] __________________________SMSBP [11] _______________________________
Company Name_________________________________________________________
NAIC Group Code_______________NAIC Company Code_______________________
Person Completing This Exhibit____________________________________________
Title_________________________ Telephone________________________________
(a) [12]
(b) [13]
(o) [14]
Cumulative Loss Ratio
(b)x(g)
Cumulative Loss Radio
(h)x(i)
Policy Year Loss Ratio
Benchmark Ratio Since Inception: (l + n)/(k + m): _________ (Ratio 1)
RATIO SINCE INCEPTION FOR GROUP POLICIES
TYPE [15] __________________________SMSBP [16] _______________________________
(a) [17]
(b) [18]
(o) [19]
(g) [ (f) ] Premium adjustments to conform with minimum standards for loss ratios. As soon as practicable, but prior to the effective date of enhancements to Medicare benefits, every issuer of Medicare supplement insurance policies, contracts, or coverage in this state shall file with the commissioner, in accordance with the applicable filing procedures of this state, the items required in paragraphs (1) and (2) of this subsection.
(1) Appropriate premium adjustments necessary to produce loss ratios as anticipated for the current premium for the applicable policies or contracts shall be filed. Documents necessary to justify the adjustment shall accompany the filing.
(A) Every issuer of Medicare supplement insurance or benefits to a resident of this state pursuant to the Insurance Code, Article 3.74 shall make premium adjustments:
(i) necessary to product an expected loss ratio under the policy or contract as will conform with the minimum loss ratio standards for Medicare supplement policies; and
(ii) expected to result in a loss ratio at least as great as that originally anticipated in the rates used to produce current premium by the issuer for the Medicare supplement insurance policies or contracts.
(B) No premium adjustment which would modify the loss ratio experience under the policy, other than the adjustments described in this subsection, should be made with respect to a policy at any time other than upon its renewal date or anniversary date.
(C) If an issuer fails to make premium adjustments acceptable to the commissioner, the commissioner may order premium adjustments, refunds, or premium credits deemed necessary to achieve the loss ratio required by this section.
(2) Any appropriate riders, endorsements, or policy forms needed to accomplish the Medicare supplement insurance modifications necessary to eliminate benefit duplications with Medicare shall be filed. The riders, endorsements, or policy forms shall provide a clear description of the Medicare supplement benefits provided by the policy or contract.
(h) [ (g) ] Maintenance of data. Incurred claims and earned premium experience shall be maintained for each policy form with business in force in Texas , by calendar year of issue, and shall be made available to the Texas Department of Insurance.
(2) The items in subparagraphs (A) - (C) of this paragraph shall be included in the outline of coverage in addition to the items specified in the plan-specific outline-of-coverage forms.
(D) The outline of coverage for Medicare Select policies or certificates shall include information regarding grievance procedures which meet the requirements of §3.3325(m) of this title (relating to Medicare Select Policies, Certificates and Plans of Operation).
Figure: 28 TAC §3.3308(c)(2)(D) FOR COPIES OF THE "NOTICE REQUIREMENTS" CONTACT SYLVIA G. AT (sylvia.gutierrez@tdi.state.tx.us)
(4) Issuers shall comply with any notice requirements of the MMA.
§3.3309. Requirements for Application Forms and Replacement Coverage.
(a) Application forms shall include the following information, statements and questions designed to elicit information as to whether, as of the date of the application, the applicant currently has another Medicare supplement , Medicare Advantage, Medicaid coverage, or other health insurance policy or certificate in force or whether a Medicare supplement policy or certificate is intended to replace any other accident and sickness policy or certificate currently [ presently ] in force. A supplementary application or other form to be signed by the applicant and agent, except where the coverage is sold without an agent, containing such questions may be used.
(1) The information shall be provided to prospective covered persons in statement form conforming to subparagraphs (A) - (F) [ (E) ] of this paragraph.
(D) If, after purchasing this policy, you become eligible for Medicaid, the [ The ] benefits and premiums under your Medicare supplement policy can be suspended, if requested, during your entitlement to benefits under Medicaid for 24 months. You must request this suspension within 90 days of becoming eligible for Medicaid. If you are no longer entitled to Medicaid, your suspended Medicare supplement policy (or, if that is no longer available, a substantially equivalent policy) will be reinstituted if requested within 90 days of losing Medicaid eligibility. If the Medicare supplement policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstituted policy will not have outpatient prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the date of the suspension.
(E) If you are eligible for, and have enrolled in a Medicare supplement policy by reason of disability and you later become covered by an employer or union-based group health plan, the benefits and premiums under your Medicare supplement policy can be suspended, if requested, while you are covered under the employer or union-based group health plan. If you suspend your Medicare supplement policy under these circumstances, and later lose your employer or union-based group health plan, your suspended Medicare supplement policy (or, if that is no longer available, a substantially equivalent policy) will be reinstituted if requested within 90 days of losing your employer or union-based group health plan. If the Medicare supplement policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstituted policy will not have outpatient prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the date of the suspension.
(F) Counseling services may be available in your state to provide advice concerning your purchase of Medicare supplement insurance and concerning medical assistance through the state Medicaid program, including benefits as a Qualified Medicare Beneficiary (QMB) and a Specified Low-Income Medicare Beneficiary (SLMB).
(2) Information shall be elicited from prospective covered persons by asking the questions as follows: If you lost or are losing other health insurance coverage and received a notice from your prior insurer saying you were eligible for guaranteed issue of a Medicare supplement insurance policy, or that you had certain rights to buy such a policy, you may be guaranteed acceptance in one or more of our Medicare supplement plans. Please include a copy of the notice from your prior insurer with your application. PLEASE ANSWER ALL QUESTIONS. Please mark Yes or No below with an "X" to the best of your knowledge.
(A) Did you turn age 65 in the last 6 months? Yes_ No___
(B) Did you enroll in Medicare Part B in the last 6 months? Yes____No____
(D) Are you covered for medical assistance through the state Medicaid program?
(i) {NOTE TO APPLICANT: If you are participating in a "Spend-Down Program" and have not met your "Share of Cost," please answer NO to this question.} Yes____ No____
(ii) If yes;
(I) Will Medicaid pay your premiums for this Medicare supplement policy? Yes____ No____
(II) Do you receive any benefits from Medicaid OTHER THAN payments toward your Medicare Part B premium? Yes____ No____
(E) If you had coverage from any Medicare plan other than original Medicare within the past 63 days (for example, a Medicare Advantage plan, or a Medicare HMO or PPO), fill in your start and end dates below. If you are still covered under this plan, leave "END" blank. START __/__/__ END __/__/__
(i) If you are still covered under the Medicare plan, do you intend to replace your current coverage with this new Medicare supplement policy? Yes____ No____
(ii) Was this your first time in this type of Medicare plan? Yes____ No____
(iii) Did you drop a Medicare supplement policy to enroll in the Medicare plan? Yes____ No____
(F) Do you have another Medicare supplement policy in force? Yes____ No____
(i) If so, with what company, and what plan do you have {optional for Direct Mailers}? _______________________________________________
(ii) If so, do you intend to replace your current Medicare supplement policy with this policy? Yes____ No____
(G) Have you had coverage under any other health insurance within the past 63 days? (For example, an employer, union, or individual plan) Yes____ No____
(i) If so, with what company and what kind of policy?
(ii) What are your dates of coverage under the other policy? START __/__/__ END __/__/__(If you are still covered under the other policy, leave "END" blank.) [ provided in subparagraphs (A) - (C) of this paragraph. ]
[ (A) Do you have another Medicare supplement insurance policy, certificate, or coverage in force? ]
[ (i) If so, with which company? ]
[ (ii) If so, do you intend to replace your current Medicare supplement policy with this policy, certificate or coverage? ]
[ (B) Do you have any other health insurance policies or coverages that provide benefits similar to this Medicare supplement policy? ]
[ (ii) What kind of policy? ]
[ (C) Are you covered for medical assistance through the state Medicaid program? ]
[ (i) If so, as a Specified Low Income Medicare Beneficiary (SLMB)? ]
[ (ii) If so, as a Qualified Medicare Beneficiary (QMB)? ]
[ (iii) If so, for other Medicaid medical benefits? ]
(f) The notice required by subsection (e) of this section shall be provided in substantially the following form and shall be in a typeface no smaller than 12-point type.
Figure: 28 TAC §3.3309(f)
NOTICE TO APPLICANT REGARDING
REPLACEMENT OF MEDICARE SUPPLEMENT INSURANCE OR
(Issuer's name and address)
SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE
According to (your application) (information you have furnished), you intend to terminate existing Medicare supplement or Medicare Advantage coverage and replace it with a policy to be issued by (Issuer's Name). Your new policy will provide 30 days within which you may decide without cost whether you desire to keep the policy. For your own information and protection, you should be aware of and seriously consider certain factors which may affect the insurance protection available to you under the new policy.
You should review this new coverage carefully. Compare it with all accident and sickness coverage you now have. Terminate your present policy or Medicare Advantage coverage only if, after due consideration and acceptance by the replacing issuer, you find that purchase of this Medicare supplement coverage is a wise decision. You should evaluate the need for other accident and sickness coverage you have that may duplicate the benefits provided under this policy.
STATEMENT TO APPLICANT BY ISSUER, (OR OTHER REPRESENTATIVE):
I have reviewed your current medical or health coverage. To the best of my knowledge, this Medicare supplement policy will not duplicate your existing Medicare supplement or, if applicable, Medicare Advantage coverage because you intend to terminate your existing Medicare supplement coverage or leave your Medicare Advantage plan . The replacement policy is being purchased for the following reasons:
________ Additional benefits,
________ Same benefits but lower premiums,
________ Fewer benefits and lower premiums,
________ My plan has outpatient prescription drug coverage and I am enrolling in Part D, Disenrollment from a Medicare Advantage plan. Please explain reason for disenrollment. [optional only for Direct Mailers.]
________ Other(specify)_____________.
I call to your attention the following items for your consideration:
(1) Health conditions which you may presently have (pre-existing conditions) may not be immediately or fully covered under the new policy. This could result in denial or delay of a claim for benefits under the new policy, whereas a similar claim might have been payable under your present policy.
(2) State law provides that your replacement policy or certificate may not contain new pre-existing conditions waiting periods, elimination periods, or probationary periods. The insurer will reduce any time periods applicable to pre-existing conditions waiting periods, elimination periods, or probationary periods in the new policy (or coverage) to the extent such time was spent (depleted) under the original policy.
(3) If you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical and health history. Failure to include all material medical information on an application may provide a basis for the issuer to deny any future claims and to refund your premium as though the policy had never been in force. After the application has been completed and before you sign it, read and review it carefully to be certain that all information has been properly recorded.
(4) Do not cancel your present policy until you have received your new policy and are sure that you want to keep it.
Signature of Agent or Other Representative
Typed Name and Address of Issuer or Agent
(g) Subsection (f)(1) and (2) of this section (applicable to preexisting conditions) may be deleted by an issuer if the replacement does not involve application of a new preexisting condition limitation.
(1) Eligible persons are those individuals described in subsection (b) of this section who seek to enroll under the Medicare supplement policy during the period specified in subsection (d) of this section, and who submit evidence of the date of termination , [ or ] disenrollment , or Medicare Part D enrollment with the application for a Medicare supplement policy.
(2) The individual is enrolled with a Medicare Advantage [ Medicare+Choice ] organization under a Medicare Advantage [ Medicare+Choice ] plan under Part C of Medicare, and any of the following circumstances apply, or the individual is 65 years of age or older and is enrolled with a Program of All-Inclusive Care for the Elderly (PACE) provider under section 1894 of the Social Security Act, and there are circumstances similar to the following that would permit discontinuance of the individual's enrollment with such provider if such individual were enrolled in a Medicare Advantage [ Medicare+Choice ] plan:
(5) The individual was enrolled under a Medicare supplement policy and terminates enrollment and subsequently enrolls, for the first time, with any Medicare Advantage [ Medicare+Choice ] organization under a Medicare Advantage [ Medicare+Choice ] plan under part C of Medicare, any eligible organization under a contract under section 1876 of the Social Security Act (Medicare cost), any similar organization operating under demonstration project authority, any PACE provider under section 1894 of the Social Security Act, or a Medicare Select policy; and the subsequent enrollment is terminated by the individual during any period within the first 12 months of such subsequent enrollment (during which the individual is permitted to terminate such subsequent enrollment under section 1851(e) of the Social Security Act); or
(6) The individual, upon first becoming enrolled in Medicare part B for benefits at age 65 or older, enrolls in a Medicare Advantage [ Medicare+Choice ] plan under part C of Medicare, or with a PACE provider under section 1894 of the Social Security Act, and disenrolls from the plan or program no later than 12 months after the effective date of enrollment.
(7) The individual enrolls in a Medicare Part D plan during the initial enrollment period and, at the time of enrollment in Part D, was enrolled under a Medicare supplement policy that covers outpatient prescription drugs and the individual terminates enrollment in the Medicare supplement policy and submits evidence of enrollment in Medicare Part D along with the application for a policy described in subsection (c)(4) of this section.
(8) The individual loses eligibility for health benefits under Title XIX of the Social Security Act (Medicaid).
(1) Subsection (b)(1), (2), (3) , [ and ] (4) , and (8) of this section is a Medicare supplement policy which has a benefit package classified as Plan A, B, C, [ or ] F (including F with a high deductible), K, or L offered by any issuer.
(2) Subsection (b)(5) of this section is the same Medicare supplement policy in which the individual was most recently previously enrolled, if available from the same issuer, or, if not so available, a policy described in paragraph (1) of this subsection. After December 31, 2005, if the individual was most recently enrolled in a Medicare supplement policy with an outpatient prescription drug benefit, the Medicare supplement policy described in this paragraph is the policy available from the same issuer but modified to remove outpatient prescription drug coverage, or at the election of the policyholder, a policy described in paragraph (1) of this subsection.
(4) Subsection (b)(7) of this section is a Medicare supplement policy that has a benefit package classified as Plan A, B, C, F (including F with a high deductible), K, or L, and that is offered and is available for issuance to new enrollees by the same issuer that issued the individual's Medicare supplement policy with outpatient prescription drug coverage.
(4) In the case of an individual described in subsections (b)(2), (4)(B) and (C), (5), or (6) of this section, who disenrolls voluntarily, the guaranteed issue period begins on the date that is 60 days before the effective date of the disenrollment and ends on the date that is 63 days after the effective date of disenrollment; [ and ]
(5) In the case of an individual described in subsection (b)(7) of this section, the guaranteed issue period begins on the date the individual receives notice pursuant to Section 1882(v)(2)(B) of the Social Security Act from the Medicare supplement issuer during the sixty-day period immediately preceding the initial Part D enrollment period and ends on the date that is 63 days after the effective date of the individual's coverage under Medicare Part D; and
(6) In the case of an individual described in subsection (b) of this section, but not described in paragraphs (1) - (5) [ (4) ] of this subsection, the guaranteed issue period begins on the effective date of disenrollment and ends on the date that is 63 days after the effective date of disenrollment.
§3.3320. Appropriateness of Recommended Purchase and Excessive Insurance.
(b) Any sale of a Medicare supplement policy or certificate that [ coverage which ] will provide an individual more than one Medicare supplement policy or certificate is prohibited.
(c) An issuer shall not issue a Medicare supplement policy or certificate to an individual enrolled in Medicare Part C unless the effective date of the coverage is after the termination date of the individual's Part C coverage.
§3.3322. Filing and Approval of Policies, Certificates and Premium Rates; Discontinuance of Forms.
(b) An issuer shall file any riders or amendments to policy or certificate forms to delete outpatient prescription drug benefits as required by the MMA only with the commissioner in the state in which the policy or certificate was issued.
(c) An issuer shall not use or change premium rates for a Medicare supplement policy or certificate unless the rates, rating schedule and supporting documentation have been filed with and approved by the commissioner in accordance with the filing requirements and procedures prescribed by the Insurance Code and this subchapter.
(d) [ (c) ] Except as provided in paragraphs (1) and (2) of this subsection, an issuer shall not file for approval more than one form of a policy or certificate of each type for each standard Medicare supplement benefit plan. For the purposes of this section, a "type" means an individual policy, a group policy, an individual Medicare Select policy, or a group Medicare Select policy. An issuer may offer, with the approval of the commissioner, one additional policy form or certificate form of the same type for the same standard Medicare supplement benefit plan, one for each of the following cases:
(1) the inclusion of new or innovative benefits; and
(2) the offering of coverage to individuals eligible for Medicare by reason of disability.
[ (d) For the purposes of this section, a "type" means an individual policy, a group policy, an individual Medicare Select policy, or a group Medicare Select policy. ]
(e) Except as provided in paragraph (1) of this subsection, an issuer shall continue to make available for purchase any policy form or certificate form issued after the effective date of this regulation that has been approved by the commissioner. A policy form or certificate form shall not be considered to be available for purchase unless the issuer has actively offered it for sale in the previous 12 months.
(2) An issuer that discontinues the availability of a policy form or certificate form pursuant to paragraph (1) of this subsection [ section ] shall not file for approval a new policy form or certificate form of the same type for the same standard Medicare supplement benefit plan as the discontinued form for a period of five years after the issuer provides notice to the commissioner of the discontinuance. The period of discontinuance may be reduced if the commissioner determines that a shorter period is appropriate.
§3.3324. Open Enrollment.
(d) Except as provided in subsection (c) of this section , §3.3312 of this chapter (relating to Guaranteed Issue for Eligible Persons), and §3.3306(1)(A) of this chapter [ title ] (relating to Minimum Benefit Standards), subsection (a) of this section shall not be construed as preventing the exclusion of benefits under a policy during the first six months, based on a preexisting condition for which the policyholder or certificate holder received treatment or was otherwise diagnosed during the six months before the coverage became effective.
§3.3325. Medicare Select Policies, Certificates and Plans of Operation.
(k) A Medicare Select issuer shall make full and fair disclosure in writing of the provisions, restrictions, and limitations of the Medicare Select policy or certificate to each applicant. This disclosure shall include at least the following:
(3) a description of the restricted network provisions, including payments for coinsurance and deductibles when providers other than network providers are utilized (except to the extent specified in the policy or certificate, expenses incurred when using out-of-network providers do not count toward the out-of-pocket annual limit contained in plans K and L) ;
(l) - (o) (No change.)
(p) For the purposes of this subsection, a Medicare supplement policy or certificate will be considered to have comparable or lesser benefits unless it contains one or more significant benefits not included in the Medicare Select policy or certificate being replaced. For the purposes of this paragraph, a significant benefit means coverage for the Medicare Part A deductible, [ coverage for prescription drugs, ] coverage for at-home recovery services, or coverage for Part B excess charges.
(q) Medicare Select policies and certificates shall provide for continuation of coverage in the event the secretary of health and human services determines that Medicare Select policies and certificates issued pursuant to this section should be discontinued due to either the failure of the Medicare Select Program to be reauthorized under law or its substantial amendment.
(2) For the purposes of this subsection, a Medicare supplement policy or certificate will be considered to have comparable or lesser benefits unless it contains one or more significant benefits not included in the Medicare Select policy or certificate being replaced. For the purposes of this paragraph, a significant benefit means coverage for the Medicare Part A deductible, [ coverage for prescription drugs, ] coverage for at-home recovery services, or coverage for Part B excess charges.
(r) (No change.)
[1] Individual, Group, Individual Medicare Select, or Group Medicare Select Only.
[2] "SMSBP" = Standardized Medicare Supplement Benefit Plan - Use "P" for pre-standardized plans.
[3] Includes Modal Loadings and Fees Charged
[4] Excludes Active Life Reserves
[5] This is to be used as "Issue Year Earned Premium" for Year 1 of next year's "Worksheet for Calculation of Benchmark Ratios"
[6] Individual, Group, Individual Medicare Select, or Group Medicare Select Only.
[7] "SMSBP" = Standardized Medicare Supplement Benefit Plan - Use "P" for pre-standardized plan.
[8] Individual, Group, Individual Medicare Select, or Group Medicare Select Only.
[9] "SMSBP" = Standardized Medicare Supplement Benefit Plan - Use "P" for pre-standardized plan.
[10] Individual, Group, Individual Medicare Select, or Group Medicare Select Only.
[11] "SMSBP" = Standardized Medicare Supplement Benefit Plan - Use "P" for pre-standardized plans.
[12] Year 1 is the current calendar year - 1. Year 2 is the current calendar year - 2 (etc.) Example: If the current year is 1991, then: Year 1 is 1990; Year 2 is 1989, etc.)
[13] For the calendar year on the appropriate line in column (a), the premium earned during that year for policies issued in that year.
[14] These loss ratios are not explicitly used in computing the benchmark loss ratios. They are the loss ratios, on a policy year basis, which result in the cumulative loss ratios displayed on this worksheet. They are shown here for informational purposes only.
[15] Individual, Group, Individual Medicare Select, or Group Medicare Select Only.
[16] "SMSBP" = Standardized Medicare Supplement Benefit Plan - Use "P" for pre-standardized plans.
[17] Year 1 is the current calendar year - 1. Year 2 is the current calendar year - 2 (etc.) Example: If the current year is 1991, then: Year 1 is 1990; Year 2 is 1989, etc.)
[18] For the calendar year on the appropriate line in column (a), the premium earned during that year for policies issued in that year.
[19] These loss ratios are not explicitly used in computing the benchmark loss ratios. They are the loss ratios, on a policy year basis, which result in the cumulative loss ratios displayed on this worksheet. They are shown here for informational purposes only.