Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-8 - MEDICARE SUPPLEMENT INSURANCE › Rule 120-2-8-.08 - Benefit Standards for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued or Delivered on or After September 30, 2005 and With an Effective Date for Coverage Prior to June 1, 2010

Current through Rules and Regulations filed through June 27, 2024
The following standards are applicable to all Medicare
				  supplement policies or certificates delivered or issued for delivery in this
				  state on or after September 30, 2005 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 through filings as otherwise provided within this Regulation
				Chapter to correspond with such changes.
(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.
1. The issuer shall not
				cancel or nonrenew the policy solely on the ground of health status of the
				individual;
2. The issuer shall not
				cancel or nonrenew the policy for any reason other than nonpayment of premium
				or material misrepresentation;
3.
				If the Medicare supplement policy is terminated by the group policyholder and
				is not replaced as provided under Section 8(1)(e)5., the issuer shall offer
				certificateholders an individual Medicare supplement policy that (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.
4. 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 Section 8(1)(e)3.,
				or
(ii) At the option of the group
				policyholder, offer the certificateholder continuation of coverage under the
				group policy.
5. 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. 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.
(f)
				Termination of a Medicare supplement policy or certificate shall be without
				prejudice to any continuous loss that 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
				the policy or certificate within ninety (90) days after the date the individual
				becomes entitled to assistance.
2.
				If suspension occurs and if the policyholder or certificateholder loses
				entitlement to medical assistance, the policy or certificate shall be
				automatically reinstituted effective as of the date of 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.
3. 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 (90) 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.
4. Reinstitution of coverages
				as described in Subparagraphs 2. and 3.:
(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. 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.
(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
				plan (as described in Section
				120-2-8-.09 of this regulation) to a
				2010 Standardized plan (as described in Section
				120-2-8-.09(8) of
				this regulation), the offer and subsequent exchange shall comply with the
				following requirements:
1. An issuer need not
				provide justification to the Commissioner if the insured replaces a 1990
				Standardized policy or certificate with an issue age rated 2010 Standardized
				policy or certificate at the insured's original issue age. 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 filed with the
				Commissioner.
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 pre-existing condition limitations or a new
				incontestability period to the new policy for those benefits contained in the
				exchanged 1990 Standardized policy or certificate of the insured, but may apply
				pre-existing condition limitations of no more than six (6) months to any added
				benefits contained in the new 2010 Standardized 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.