Hawaii Administrative Rules › Title 16 - DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS › Chapter 12 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 16-12-5.6 - Benefit standards for 2010 standardized Medicare supplement benefit plan policies or certificates issued or delivered with an effective date for coverage on or after June 1, 2010

Current through June, 2024
(a) 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 (Exhibit A (revised 2019)). 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
			 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 prior to June 1, 2010, remain subject to
			 the requirements of sections
			 16-12-5.5
			 or
			 16-12-6.
(b) General standards. The following
			 standards apply to Medicare supplement policies and certificates and are in
			 addition to all other requirements of this chapter (Exhibit A (revised 2019)).
(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 non-renew the policy solely on the ground of health status of the
			 individual.
(B) The issuer shall
			 not cancel or non-renew the policy for any reason other than nonpayment of
			 premium or material misrepresentation.
(C) If the Medicare supplement policy is
			 terminated by the group policyholder and is not replaced as provided under
			 subparagraph (E), the issuer shall offer certificate holders an individual
			 Medicare supplement policy which at the option of the certificate holder:
(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 certificate holder
			 in a group Medicare supplement policy and the individual terminates membership
			 in the group, the issuer shall:
(i) Offer the
			 certificate holder the conversion opportunity described in subparagraph (C); or
(ii) At the option of the group
			 policyholder, offer the certificate holder 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 will 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
			 certificate holder for the period (not to exceed twenty-four months) in which
			 the policyholder or certificate holder 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 certificate holder notifies the issuer of the
			 policy or certificate within ninety days after the date the individual becomes
			 entitled to assistance.
(B) If
			 suspension occurs and if the policyholder or certificate holder loses
			 entitlement to medical assistance, the policy or certificate shall be
			 automatically reinstituted (effective as of the date of termination of
			 entitlement) as of the termination of entitlement if the policyholder or
			 certificate holder provides notice of loss of entitlement within ninety days
			 after the date of loss and pays the premium attributable to the period,
			 effective as of the date of termination of entitlement.
(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 suspension occurs
			 and if the policyholder or certificate holder loses coverage under the group
			 health plan, the policy shall be automatically reinstituted (effective as of
			 the date of loss of coverage) if the policyholder provides notice of loss of
			 coverage within ninety days after the date of the loss and pays the premium
			 attributable to the period, effective as of the date of termination of
			 enrollment in the group health plan.
(D) Reinstitution of coverages as described
			 in subparagraphs (B) and (C):
(i) Shall not
			 provide for any waiting period with respect to treatment of preexisting
			 conditions;
(ii) Shall provide for
			 resumption of coverage that is substantially equivalent to coverage in effect
			 before the date of suspension; and
(iii) Shall 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.