Hawaii Administrative Rules › Title 16 - DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS › Chapter 12 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 16-12-5.5 - Benefit standards for 1990 standardized Medicare supplement benefit plan policies or certificates issued or delivered on or after September 3, 1992, and with an effective date for coverage prior to 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 on or after September 3, 1992, and with an effective
			 date for coverage prior to 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.
(b)
			 The following are general standards that 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 those 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 and:
(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 the 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; and
(F) 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.
(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 that assistance.
(B) If
			 the suspension occurs and if the policyholder or certificate holder loses
			 entitlement to the medical assistance, the policy or certificate shall be
			 automatically reinstituted (effective as of the date of termination of that
			 entitlement) if the policyholder or certificate holder provides notice of loss
			 of the entitlement within ninety days after the date of the loss and pays the
			 premium attributable to the period.
(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
			 entitlement in the group health plan.
(D) Reinstitution of the coverages as
			 provided 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 the 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 certificate holder as the premium classification terms that
			 would have applied to the policyholder or certificate holder had the coverage
			 not been suspended.
(8) If an issuer makes a written offer to the
			 Medicare supplement policyholders or certificate holders of one or more of its
			 plans, to exchange during a specified period from his or her 1990 standardized
			 plan (as described in section
			 16-12-6
			 ) to a 2010 standardized plan (as described in section
			 16-12-6.05
			 ), the offer and subsequent exchange shall comply with the following
			 requirements:
(A) 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 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 filed with the
			 commissioner.
(B) The rating class
			 of the new policy or certificate shall be the class closest to the insured's
			 class of the replaced coverage.
(C)
			 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 policy or certificate of the insured, but may apply
			 preexisting condition limitations of no more than six months to any added
			 benefits contained in the new 2010 standardized policy or certificate not
			 contained in the exchanged policy.
(D) The new policy or certificate shall be
			 offered to all policyholders or certificate holders within a given plan, except
			 where the offer or issue would be in violation of state or federal
			 law.