California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 1.6 - Medicare Supplement Coverage › Section 2220.52 - General Policy Provisions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The following shall be applicable to "Medicare Supplement
					 Coverage" and shall be in addition to the requirements of Article 1.5, above.
					 These are minimum standards and do not preclude the inclusion of additional
					 benefits in such coverages:
(a)
				  Pre-existing condition limitations shall not exclude coverage for more than six
				  months after the effective date of coverage under the policy for a condition
				  for which medical advice was given or treatment was recommended by or received
				  from a physician within six (6) months before the effect date of the
				  coverage;
(b) The term "Medicare
				  benefit period" shall mean the unit of time used in the Medicare program to
				  measure use of services and availability of benefits under Part A Medicare
				  hospital insurance;
(c) The term
				  "Medicare eligible expenses" shall mean health care expenses of the kinds
				  covered by Medicare, to the extent recognized as reasonable by Medicare.
				  Payment of benefits by insurers for Medicare eligible expenses may be
				  conditioned upon the same or less restrictive payment conditions, including
				  determinations of medical necessity as are applicable to Medicare
				  claims;
(d) The term "Physician"
				  shall mean a licensed practitioner of the healing arts, practicing within the
				  scope of the practicioner's license. It includes all practitioners described in
				  Insurance Code Section
				  10176.
(e) The term "nurse" shall mean a registered
				  nurse (R.N.) or a licensed vocational nurse (L.V.N.).
(f) The term "Medicare" shall mean the Health
				  Insurance for the Aged Act, Title XVIII of the Social Security Amendments of
				  1965 as then constituted or later amended.
(g) The terms "Medicare Supplement,"
				  "Medigap" and words of similar import shall not be used to describe a policy
				  unless the policy is issued in compliance with this Article.
(h) Coverage, when issued, shall not be
				  subject to any exclusions, limitations, or reductions (other than as permitted
				  in this Article and other applicable laws and regulations) which are
				  inconsistent with the exclusions, limitations, or reductions permissible under
				  Medicare, other than a provision that coverage is not provided for any expenses
				  to the extent of any benefit available to the insured person under
				  Medicare.
(i) Coverage shall not
				  idemnify against losses resulting from sickness on a different basis than
				  losses resulting from accidents;
(j) Coverage 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 amount and co-payment percentage factors; and
(k) Policies providing convalescent or
				  extended care benefits shall not condition such benefits upon admission to the
				  convalescent or extended care facility within a period of less than fourteen
				  (14) days after discharge from the hospital, nor shall they require a hospital
				  confinement exceeding three (3) days.
1. Change
					 without regulatory effect amending subsection (d) filed 7-14-2021 pursuant to
					 section 100, title 1, California Code of
					 Regulations (Register 2021, No. 29). Filing deadline specified in Government
					 Code section
					 11349.3(a)
					 extended 60 calendar days pursuant to Executive Order
					 N-40-20.
Note: Authority cited: Sections
						10291.5
						(c) and
						10195 (5)
						(b), Insurance Code. Reference: Section
						10291.5(b)
						(7), Insurance
						Code.