Alabama Administrative Code › Title 482 - ALABAMA DEPARTMENT OF INSURANCE › Chapter 482-1-071 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS REGULATION › Section 482-1-071-.08-1 - 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. 42, No. 9, June 28, 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 prior to June 1, 2010 remain subject to the
				requirements of
				482-1-071-.08.
A. General Standards. The following standards
			 apply to Medicare supplement policies and certificates and are in addition to
			 all other requirements of this chapter.
(1) 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.
(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
			 482-1-071-.08 -1A(5)(e) of this
			 chapter, 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
			 482-1-071-.08 -1A(5)(c) of this
			 chapter; 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.
(f) Rate increases
			 otherwise authorized by law are not prohibited by this Paragraph (5).
(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
			 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.
(b)
			 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, effective as of the date of termination of
			 entitlement.
(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 (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.
(d)Reinstitution of coverages as described 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 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.