Illinois Administrative Code › Title 50 - INSURANCE › Part 2008 - MINIMUM STANDARDS FOR INDIVIDUAL AND GROUP MEDICARE SUPPLEMENT INSURANCE › Subpart B - COVERAGE, POLICY & BENEFIT PROVISIONS › Section 2008.64 - Benefit Standards for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery with an Effective Date for Coverage on or after June 1, 2010

Current through Register Vol. 48, No. 28, July 12, 2024
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
				  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 before June 1, 2010 remain subject to the
				  requirements of Section
				  2008.70
				  for Pre-Standardized Plans or Section
				  2008.71
				  for 1990 Plans.
a) General Standards.
				The following standards apply to Medicare supplement policies and certificates
				and are in addition to all other requirements of this Part.
1) A Medicare supplement policy or
				certificate shall not exclude or limit benefits for losses incurred more than 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 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.
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 nonrenew the policy solely on the ground of health status of the
				individual.
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 subsection (a)(5)(E), 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 benefits that otherwise meet
				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 subsection (a)(5)(C);
				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 will not be considered in determining a continuous
				loss.
7) 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 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 ( 42 USC 1901-1941 ), but only if the
				policyholder or certificateholder notifies the issuer of the policy or
				certificate within 90 days after the date the individual becomes entitled to
				assistance. In no case shall the suspension exceed 24 months.
A) 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 90 days after the date of loss
				and pays the premium attributable to the period, effective as of the date of
				termination of entitlement.
B) 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 (
				42 USC
				426(b) ) and is covered
				under a group health plan (as defined in section 1862(b)(1)(A)(v) of the Social
				Security Act (
				42 USC
				1395y(b)(1)(A)(v) ). 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 and pays
				the premium attributable to the period, effective as of the date of termination
				of enrollment in the group health plan.
C) Reinstitution of coverages as described in
				subsections (a)(7)(A) and (B):
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
				certificateholder as the premium classification terms that would have applied
				to the policyholder or certificateholder had the coverage not been
				suspended.