Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.10 - MEDICARE SUPPLEMENT INSURANCE STANDARDS › Section 18.04.10.022 - BENEFIT STANDARDS FOR 2010 STANDARDIZED BENEFIT PLAN POLICIES OR CERTIFICATES ISSUED FOR DELIVERY WITH AN EFFECTIVE DATE FOR COVERAGE ON OR AFTER JUNE 1, 2010

Current through August 31, 2023
The following standards 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 unless it complies
				with these benefit standards. No issuer may offer any 1990 Standardized benefit
				plan for sale on or after June 1, 2010. Benefit standards applicable to
				policies and certificates issued with an effective date for coverage prior to
				June 1, 2010 remain in effect. (3-31-22)
01.
General Standards
. The
			 following standards apply to Medicare supplement policies and certificates and
			 are in addition to all other requirements of this regulation. (3-31-22)
a. A Medicare supplement policy or
			 certificate cannot exclude or limit benefits for losses incurred more than six
			 (6) months from the effective date of coverage because it involved a
			 preexisting condition. The policy or certificate will 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
			 (6) months before the effective date of coverage. (3-31-22)
b. A Medicare supplement policy or
			 certificate will not indemnify against losses resulting from sickness on a
			 different basis than losses resulting from accidents. (3-31-22)
c. A Medicare supplement policy or
			 certificate provides 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. (3-31-22)
d. No Medicare supplement policy or
			 certificate may 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. (3-31-22)
e. Each Medicare supplement policy is
			 guaranteed renewable. (3-31-22)
i. The issuer
			 cannot cancel or nonrenew the policy solely on the ground of health status of
			 the individual. (3-31-22)
ii. The
			 issuer cannot cancel or nonrenew the policy for any reasons other than
			 nonpayment of premium or material representation. (3-31-22)
iii. If the Medicare supplement policy is
			 terminated by the group policyholder and is not replaced as provided under
			 Subparagraph 022.01.e.v., the issuer offers certificateholders an individual
			 Medicare supplement policy which (at the option of the certificateholder):
			 (3-31-22)
(1) Provides for continuation of the
			 benefits contained in the group policy; or (3-31-22)
(2) Provides for benefits that meet the
			 requirements of this Subsection. (3-31-22)
iv. If an individual is a certificateholder
			 in a group Medicare supplement policy and the individual terminates membership
			 in the group, the issuer: (3-31-22)
(1) Offers
			 the certificateholder the conversion opportunity described in Subparagraph
			 022.01.e.iii.; or (3-31-22)
(2) At
			 the option of the group policyholder, offers the certificate holder
			 continuation of coverage under the group policy. (3-31-22)
v. 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 offers coverage to all
			 persons covered under the old group policy on its date of termination. Coverage
			 under the new policy cannot exclude preexisting conditions that would have been
			 covered under the group policy being replaced. (3-31-22)
f. Terminations of a Medicare supplement
			 policy or certificate need to be without prejudice to any continuous loss that
			 commenced while the policy was in force. Such 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 will not be considered in determining a continuous
			 loss. (3-31-22)
g. A Medicare
			 supplement policy or certificate provides that benefits and premiums under the
			 policy or certificate may be suspended at the request of the policyholder or
			 certificateholder for the period (not to exceed twenty-four (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, but only if the policyholder or certificateholder notifies the issuer of
			 the policy or certificate within ninety (90) days after the date the individual
			 becomes entitled to assistance. (3-31-22)
i.
			 If suspension occurs and if the policyholder or certificateholder loses
			 entitlement to medical assistance, the policy or certificate is automatically
			 reinstituted (effective as of the date of termination of entitlement) as of the
			 termination of entitlement if the policyholder or certificateholder provides
			 notice of loss of entitlement within ninety (90) days after the date of loss
			 and pays the premium attributable to the period, effective as of the date of
			 termination of entitlement. (3-31-22)
ii. Each Medicare supplement policy provides
			 that benefits and premiums under the policy may 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 suspension
			 occurs and if the policyholder or certificateholder loses coverage under the
			 group health plan, the policy is automatically reinstituted (effective as of
			 the date of loss of coverage) if the policyholder provides notice of loss of
			 coverage within (90) days after the date of the loss and pays the premium
			 attributed to the period, effective as of the date of termination of enrollment
			 in the group health plan. (3-31-22)
iii. Reinstitution of coverages as described
			 in Subparagraphs 022.01.g.i. and 022.01.g.ii.; (3-31-22)
(1) Does not provide for any waiting period
			 with respect to treatment of preexisting conditions; (3-31-22)
(2) Provides for resumption of coverage that
			 is substantially equivalent to coverage in effect before the date of
			 suspension; and (3-31-22)
(3)
			 Provides for classification of premiums on terms at least as favorable to the
			 policyholder or certificateholder as the premium classification terms that
			 would have applied to the policyholder or certificateholder had the coverage
			 not been suspended. (3-31-22)
h. An issuer makes available to each
			 prospective policyholder and certificateholder a policy form or certificate
			 form containing only the basic (core) benefits, as defined in Subsection
			 022.02. (3-31-22)
i. If an issuer makes available any of the
			 additional benefits described in Subsection
			 022.03, or offers standardized
			 benefit Plans K or L (as described in Paragraphs 022.04.h. and 022.04.i.), then
			 the issuer makes available to each prospective policyholder and
			 certificateholder, in addition to a policy form or certificate form with only
			 the basic (core) benefits as described in Paragraph 022.01.h., a policy form or
			 certificate form containing either standardized benefit Plan C (as described in
			 Paragraph 022.04.c.) or standardized benefit Plan F (as described in Paragraph
			 022.04.e.). (3-31-22)
j. No groups,
			 packages or combinations of Medicare supplement benefits other than those
			 listed in this section are offered for sale in this state, except as may be
			 permitted in Subsection
			 022.05 and in Section
			 031. (3-31-22)
k. Benefit plans are uniform in structure,
			 language, designation and format to the standard benefit plans listed in this
			 Subsection and conform to the definitions in Section
			 010. Each benefit is structured in
			 accordance with the format provided in Subsections
			 022.02 and
			 022.03; or, in the case of plans
			 K or L, in Paragraphs 022.04.h. and 022.04.i. and list the benefits in the
			 order shown. For purposes of this section, "structure, language, and format"
			 means style, arrangement and overall content of benefit. (3-31-22)
l. In addition to the benefit plan
			 designations prescribed in Paragraph 022.01.k., an issuer may use other
			 designations to the extent permitted by law. (3-31-22)