Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-156 - MEDICARE SUPPLEMENT INSURANCE › Section 69O-156.007 - Benefit Standards for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued or Delivered on or After January 1, 1992, and with an Effective Date for Coverage Prior to June 1, 2010

Current through Reg. 50, No. 138; July 16, 2024
The following standards are applicable to all 1990
				  standardized Medicare supplement benefit plan policies or certificates
				  delivered or issued for delivery in this state on or after January 1, 1992, and
				  with an effective date for coverage prior to 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.
(1)
				General Standards. The following standards apply to Medicare supplement
				policies and certificates and are in addition to all other requirements of this
				regulation.
(a) 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.
(b) A Medicare supplement policy or
				certificate shall not indemnify against losses resulting from sickness on a
				different basis than losses resulting from accidents.
(c) 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. The premium changes must be
				submitted to and approved by the Office pursuant to Sections
				627.410,
				627.411 and
				627.674, F.S.
(d) 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.
(e) Each Medicare supplement policy shall be
				guaranteed renewable and:
1. The issuer shall
				not cancel or nonrenew the policy solely on the ground of health status of the
				individual; and
2. The issuer shall
				not cancel or nonrenew the policy for any reason other than nonpayment of
				premium or material misrepresentation.
3.
a. If
				the Medicare supplement policy is terminated by the group policyholder and is
				not replaced as provided under subparagraph
				69O-156.007(1)(e)
				5., F.A.C., 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 rule.
b. In either case, if the group policy was
				issued on an issue age basis, the individual Medicare supplement policy is
				issued at the original issue age of the terminated certificateholder, and is at
				the duration of the terminated certificate at the time of
				conversion.
4. If an
				individual is a certificateholder in a group Medicare supplement policy and the
				individual terminates membership in the group, the issuer shall:
a. Offer the certificateholder the conversion
				opportunity described in subparagraph
				69O-156.007(1)(e)
				3., F.A.C., or
b. At the option of
				the group policyholder, offer the certificateholder continuation of coverage
				under the group policy.
5.
a. If a
				group Medicare supplement policy is replaced by another group Medicare
				supplement policy purchased by the same policyholder, the succeeding issuer
				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.
b. If
				the terminated group policy was issued on an issue age basis and the policy
				reserves are transferred to the new insurer, the new group certificates shall
				retain the original issue ages of the insureds and shall commence at the same
				duration as the terminated certificates.
6. 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 paragraph.
7. If an
				individual Medicare supplement policy/certificate is issued to replace an
				existing issue age rated policy/certificate of the same insurer, the replacing
				policy shall be issued at the original issue age of the
				policyholder/certificateholder, and is at the duration of the terminated
				policy/certificate at the time of replacement.
(f) 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.
(g)
1. 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. Upon receipt of timely notice,
				the issuer shall return to the policyholder or certificateholder that portion
				of the premium attributable to the period of Medicaid eligibility, subject to
				adjustment for paid claims.
2. 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.
3. Each Medicare supplement policy shall
				provide that benefits and premiums under the policy shall be suspended (for any
				period that is 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 90 days after the date of the loss of coverage and pays the
				premium attributable to the period, effective as of the date of termination of
				enrollment in the group health plan.
4. Reinstitution of such coverages as
				described in subparagraphs 2. and 3.:
a. Shall
				not provide for any waiting period with respect to treatment of preexisting
				conditions;
b. Shall provide for
				resumption of coverage that 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 of 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
c. 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.
(h)
				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 from his or her 1990 Standardized benefit plan, as described in Rule
				69O-156.008, F.A.C., to a 2010
				Standardized benefit plan, as described in Rule
				69O-156.0085, F.A.C., the offer
				and subsequent exchange shall comply with the following requirements:
1. An issuer need not provide justification
				to the Office if the insured replaces a 1990 Standardized benefit plan policy
				or certificate with an issue age rated 2010 Standardized benefit plan policy or
				certificate at the insured's original issue age and duration. If an insured's
				policy or certificate to be replaced is priced on an issue age rate schedule at
				the time of such offer, the rate charged to the insured for the new exchanged
				policy shall recognize the policy reserve buildup, due to the pre-funding
				inherent in the use of an issue age rate basis, for the benefit of the insured.
				The method proposed to be used by an issuer must be submitted to and approved
				by the Office pursuant to Sections
				627.410,
				627.411 and
				627.674, F.S.
2. The rating class of the new policy or
				certificate shall be the class closest to the insured's class of the replaced
				coverage.
3. An issuer may not
				apply new preexisting condition limitations or a new incontestability period to
				the new policy for those benefits contained in the exchanged 1990 Standardized
				benefit plan policy or certificate of the insured, but may apply preexisting
				condition limitations of no more than six (6) months to any added benefits
				contained in the new 2010 Standardized benefit plan policy or certificate not
				contained in the exchanged policy.
4. 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.