Connecticut Administrative Code › Title 38a - Insurance Department › 495a - Medicare Supplement Insurance › Section 38a-495a-5a - Benefit standards for 2010 standardized Medicare supplement benefit plan policies or certificates issued for delivery with an effective date for coverage on or after June 1, 2010

Current through July 10, 2024
The standards established in this section are applicable to all
				Medicare supplement policies or certificates delivered or issued for delivery
				in this state with an effective date for 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 on or
				after June 1, 2010 unless it complies with benefit standards established in
				this section. No issuer may offer any 1992 Medicare standardized Medicare
				supplement benefit plan for sale on or after June 1, 2010. Benefit standards
				applicable to Medicare supplement policies and certificates issued with an
				effective date for coverage on or after July 30, 1992, and before June 1, 2010,
				remain subject to the requirements of 38a-495a-5 and 38a-495a-6 of the
				Regulations of Connecticut State Agencies.
(a)
General Standards
. The
			 standards established in this subsection apply to Medicare supplement policies
			 and certificates delivered or issued for delivery in this state with an
			 effective date for coverage on or after June 1, 2010 and are in addition to all
			 other requirements of sections
			 38a-495a-1
			 to
			 38a-495a-21,
			 inclusive, of the Regulations of Connecticut State Agencies.
(1) A Medicare supplement policy or
			 certificate shall not exclude or limit benefits for losses incurred more than
			 six months from the effective date of coverage because it involved a
			 preexisting condition. The policy or certificate may not define a preexisting
			 condition more restrictively than a condition for which medical advice was
			 given or treatment was recommended by or received from a physician within six
			 months before the effective date of coverage.
(2) A Medicare supplement policy or
			 certificate shall not indemnify against losses resulting from sickness on a
			 different basis than losses resulting from accidents.
(3) A Medicare supplement policy or
			 certificate shall provide that benefits designed to cover cost sharing amounts
			 under Medicare will be changed automatically to coincide with any changes in
			 the applicable Medicare deductible, copayment, or coinsurance amounts. Premiums
			 may be modified to correspond with such changes.
(4) No Medicare supplement policy or
			 certificate shall provide for termination of coverage of a spouse solely
			 because of the occurrence of an event specified for termination of coverage of
			 the insured, other than the nonpayment of premium.
(5) Each Medicare supplement policy shall be
			 guaranteed renewable.
(A) The issuer shall not
			 cancel or nonrenew the policy solely on the ground of health status of the
			 individual.
(B) The issuer shall
			 not cancel or nonrenew the policy for any reason other than nonpayment of
			 premium or material misrepresentation.
(C) If a Medicare supplement policy is
			 terminated by a group policyholder and is not replaced as provided under
			 subparagraph (E) of this subdivision of this section, the issuer shall offer
			 certificateholders an individual Medicare supplement policy which, at the
			 option of the certificateholder, (i) provides for continuation of the benefits
			 contained in the group policy, or (ii) provides for benefits that otherwise
			 meet the requirements of this subsection.
(D) If an individual is a certificateholder
			 in a group Medicare supplement policy and the individual terminates membership
			 in the group, the issuer shall offer the certificateholder (i) the conversion
			 opportunity described in subparagraph (C) of this subdivision, or (ii) at the
			 option of the group policyholder, continuation of coverage under the group
			 policy.
(E) If a group Medicare
			 supplement policy is replaced by another group Medicare supplement policy
			 purchased by the same policyholder, the issuer of the replacement policy shall
			 offer coverage to all persons covered under the old group policy on its date of
			 termination. Coverage under the new policy shall not result in any exclusion
			 for preexisting conditions that would have been covered under the group policy
			 being replaced.
(6)
			 Termination of a Medicare supplement policy or certificate 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 conditioned upon the continuous total disability of the insured,
			 limited to the duration of the policy benefit period, if any, or payment of the
			 maximum benefits. Receipt of Medicare Part D benefits shall not be considered
			 in determining a continuous loss.
(7)
(A) A
			 Medicare supplement policy or certificate shall provide that benefits and
			 premiums under the policy or certificate shall be suspended at the request of
			 the policyholder or certificateholder for the period, not to exceed 24 months,
			 in which the policyholder or certificateholder has applied for and is
			 determined to be entitled to medical assistance under Title XIX of the Social
			 Security Act, provided the policyholder or certificateholder notifies the
			 issuer of the policy or certificate not later than ninety days after the date
			 the individual becomes entitled to assistance.
(B) If such suspension occurs and the
			 policyholder or certificateholder loses entitlement to medical assistance under
			 Title XIX of the Social Security Act, the policy or certificate shall be
			 automatically reinstituted effective as of the date of termination of
			 entitlement provided the policyholder or certificateholder provides notice of
			 loss of entitlement not later than ninety days after the date of loss and pays
			 the premium attributable to the period.
(C) Each Medicare supplement policy shall
			 provide that benefits and premiums under the policy shall be suspended, for any
			 period that may be provided by federal regulation, at the request of the
			 policyholder if the policyholder is entitled to benefits under section 226(b)
			 of the Social Security Act and is covered under a group health plan, as defined
			 in section 1862(b)(1)(A)(v) of the Social Security Act. If such suspension
			 occurs and the policyholder or certificateholder loses coverage under the group
			 health plan, the policy shall be automatically reinstituted effective as of the
			 date of loss of coverage, provided the policyholder provides notice of loss of
			 coverage not later than ninety days after the date of the loss and pays the
			 premium attributable to the period as of the date of termination of enrollment
			 in the group health plan.
(D)
			 Reinstitution of coverages as set forth in subparagraphs (B) and (C) of this
			 subdivision shall:
(i) Not provide for any
			 waiting period with respect to treatment of preexisting conditions;
(ii) Provide for resumption of coverage that
			 is substantially equivalent to the coverage that was in effect before the date
			 of suspension; and
(iii) Provide
			 for classification of premiums on terms at least as favorable to the
			 policyholder or certificate holder as the premium classification terms that
			 would have applied to the policyholder or certificate holder had the coverage
			 not been suspended.