Connecticut Administrative Code › Title 38a - Insurance Department › 495a - Medicare Supplement Insurance › Section 38a-495a-5 - Benefit standards for policies or certificates issued or delivered on or after July 30, 1992 and with an effective date for coverage prior to June 2010

Current through July 10, 2024
The following standards are applicable to all Medicare
				supplement policies or certificates delivered or issued for delivery in this
				state on or after July 30, 1992 and with an effective date for coverage prior
				to June 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.
(a)
General Standards
. The
			 following standards apply to Medicare supplement policies and certificates and
			 are in addition to all other requirements of this regulation.
(1) A Medicare supplement policy or
			 certificate shall not 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 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
			 (6) 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 only with the prior approval of
			 the commissioner.
(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 and;
(A) The issuer shall
			 not cancel or nonrenew the policy solely on the ground of health status of the
			 individual; and
(B) The issuer
			 shall not cancel or nonrenew 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) of this subdivision, 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 such benefits as otherwise
			 meets 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:
(i) Offer the
			 certificateholder the conversion opportunity described in subparagraph (C) of
			 this subdivision, or
(ii) At the
			 option of the group policyholder, offer the certificateholder 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) If a Medicare supplement policy
			 eliminates an outpatient prescription drug benefit as a result of requirements
			 imposed by the Medicare Prescription Drug, Improvement, and Modernization Act
			 of 2003, the modified policy shall be deemed to satisfy the guaranteed renewal
			 requirements of this subsection.
(8)
(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 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 such policy or certificate within ninety (90) days after the date
			 the individual becomes entitled to such assistance.
(B) If such suspension occurs and if the
			 policyholder or certificateholder loses entitlement to such medical assistance,
			 such policy or certificate shall be automatically reinstituted (effective as of
			 the date of termination of such entitlement) as of the termination of such
			 entitlement if the policyholder or certificateholder provides notice of loss of
			 such entitlement within ninety (90) days after the date of such loss and pays
			 the premium attributable to the period, effective as of the date of termination
			 of such entitlement.
(C) Each
			 Medicare supplement policy or certificate shall provide that benefits and
			 premiums under the policy or certificate shall be suspended (for any period
			 that may be provided by federal regulation) at the request of the policyholder
			 or certificateholder if the policyholder or certificate holder 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 if the policyholder or
			 certificateholder loses coverage under the group health plan, the policy or
			 certificate shall be automatically reinstituted (effective as of the date of
			 loss of such coverage) if the policyholder or certificateholder provides notice
			 of loss of coverage within 90 days after the date of such loss of
			 coverage.
(D) Reinstitution of
			 coverage as described in subparagraphs (B) and (C) of this subdivision:
(i) Shall not provide for any waiting period
			 with respect to treatment of preexisting conditions;
(ii) Shall provide for resumption of coverage
			 which is substantially equivalent to coverage in effect before the date of
			 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 suspension; and
(iii) Shall provide 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.
(9) If an issuer makes a written offer to the
			 Medicare supplement policyholders or certificateholders of one or more of its
			 plans, to exchange during a specified period his or her 1992 standardized
			 benefit plan as described in section
			 38a-495a-6
			 of the Regulations of Connecticut State Agencies, for a 2010 standardized
			 benefit plan as described in section
			 38a-495a-6
			 a of the Regulations of Connecticut State Agencies, the offer and subsequent
			 exchange shall comply with the following requirements:
(A) An issuer may not apply new pre-existing
			 limitations or a new incontestability period to the new policy for those
			 benefits contained in the exchanged 1992 standardized policy or certificate of
			 the insured, but may apply pre-existing condition limitations of no more than
			 six months to any added benefits contained in the new 2010 standardized benefit
			 plan not contained in the exchanged plan.
(B) The new policy or certificate shall be
			 offered to all policyholders or certificateholders within a given plan except
			 where the offer or issue would be in violation of state or federal
			 law.