Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-156 - MEDICARE SUPPLEMENT INSURANCE › Section 69O-156.0075 - 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 Reg. 50, No. 138; July 16, 2024
The following standards are applicable to all 2010
				  Standardized 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 Rules
				  69O-156.006,
				  69O-156.007, and
				  69O-156.008, F.A.C.
(1) General Standards. The following
				standards apply to Medicare supplement policies and certificates and are in
				addition to all other requirements of this rule.
(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, co-payment, or coinsurance amounts.
				Premiums may be modified to correspond with such changes. The premium changes
				must be submitted to and approved by the Office pursuant to Sections
				627.410,
				627.411, and
				627.674, F.S.
(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.
a. If the Medicare supplement policy is
				terminated by the group policyholder and is not replaced as provided under
				subparagraph 69O-156.0075(1)(e)
				5., F.A.C., 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 rule.
b. In either case, if the group policy was
				issued on an issue age basis, the individual Medicare supplement policy is
				issued at the original issue age of the terminated certificateholder, and is at
				the duration of the terminated certificate at the time of
				conversion.
4. If an
				individual is a certificateholder in a group Medicare supplement policy and the
				individual terminates membership in the group, the issuer shall:
a. Offer the certificateholder the conversion
				opportunity described in subparagraph
				69O-156.0075(1)(e)
				3., F.A.C.; or
b. At the option of
				the group policyholder, offer the certificateholder continuation of coverage
				under the group policy.
5.
a. 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.
b. If the terminated group policy was issued
				on an issue age basis and the policy reserves are transferred to the new
				insurer, the new group certificates shall retain the original issue ages of the
				insureds and shall commence at the same duration as the terminated
				certificates.
6. If an
				individual Medicare supplement policy/certificate is issued to replace an
				existing issue age rated policy/certificate of the same insurer, the replacing
				policy/certificate shall be issued at the original issue age of the
				policyholder/certificateholder, and is at the duration of the terminated
				policy/certificate at the time of replacement.
(f) 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.
(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) as of the 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.
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 certificateholder 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.:
a. Shall not provide
				for any waiting period with respect to treatment of preexisting
				conditions;
b. Shall provide for
				resumption of coverage that is substantially equivalent to coverage in effect
				before the date of suspension; and
c. 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.