Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 275 - Medicare Supplement Insurance › Section 031-275-8 - Benefit Standards for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or after January 1, 1992 and with an Effective Date of Coverage Prior to 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 on or after January 1, 1992 and with an effective date of coverage prior
				  to 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.
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 the loss 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; and
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
				Section 8(A)(5)(e), the issuer shall offer each certificate holder 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 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 Section 8(A)(5)(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.
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.
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
				certificate holder for the period (not to exceed twenty-four (24) 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
				such policy or certificate within ninety (90) days after the date the
				individual is notified that he or she is entitled to such assistance.
b. If suspension occurs and if the
				policyholder or certificate holder loses entitlement to medical assistance,
				such policy or certificate shall be automatically reinstituted, effective as of
				the date of termination of such entitlement, if the policyholder or certificate
				holder provides notice of loss of entitlement within ninety (90) days after the
				date he or she is notified 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 the
				period 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 90 days after the date of such loss and pays the premium attributable to
				the period beginning on the date of termination of entitlement.
d. Reinstitution of such coverages:
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 such
				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)
				An issuer must make a written offer to each of its Medicare supplement
				policyholders or certificate holders with a 1990 standardized plan (as
				described in Section
				9 of this Rule) to exchange the plan
				for a 2010 standardized plan (as described in Section
				9.1 of this Rule). A written offer
				to exchange the plan for a current standardized plan must also be included in
				any subsequent notice of rate increase. The plans offered and any subsequent
				exchange must be consistent with Sections
				12(D) and
				23.