Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 275 - Medicare Supplement Insurance › Section 031-275-8.1 - Benefit Standards for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery with an Effective Date of Coverage on or After June 1, 2010

Current through 2024-29, July 17, 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 of 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 of coverage before June 1, 2010 remain subject to the
				  requirements of Section
				  8.
A. General Standards. The following standards
				apply to Medicare supplement policies and certificates and are in addition to
				all other requirements of this Rule.
(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, co-payment, 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 non-renew the policy 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 policy holder and
				is not replaced as provided under Section 8.1(A)(5)(e) of this Rule, the issuer
				shall offer each certificateholder 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 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 Section 8.1(A)(5)(c)
				of this Rule; 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.
A carrier issuing a subsequent Medicare supplement policy may
				  not deny any claim otherwise covered under the policy on the basis that the
				  enrollee is entitled to an extension of coverage under a prior policy pursuant
				  to this paragraph, unless the prior carrier has paid the claim or has agreed in
				  writing that it is providing coverage for the claim. If the prior carrier does
				  not agree in writing to provide coverage for the claim, any disputes over the
				  carriers' respective responsibilities for payment may be resolved in accordance
				  with the procedures applicable to medical coverage as set forth in Bureau of
				  Insurance Rule 790.
(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 policy holder 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 certificate holder provides notice of loss
				of entitlement within ninety (90) days after the date of loss and pays the
				premium attributable to the period beginning on 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 policy holder 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 beginning on 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 policy holder or certificateholder had the coverage not been
				suspended.