Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 10 - Regulation to Implement the Medicare Supplement Insurance Minimum Standards Model Act, as amended › Rule 19-3-10.08

Current through June 25, 2024
Benefit Standards for 1990 Standardized Medicare Supplement
				  Benefit Plan Policies or Certificates Issued For Delivery After July 1, 1992
				  With An Effective Date For Coverage Prior To June 1, 2010
The following standards are applicable to all Medicare
				  supplement policies or certificates delivered or issued for delivery in this
				  state on or after July 1, 1992 and with an effective date for 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 regulation.
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 solely 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 policyholder and is not replaced as provided under Rule
				10.08 A(5)(e), the issuer shall offer certificate holders 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 Rule 10.08 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.
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 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 certificate holder 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 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, 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. 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. If an issuer makes a written offer to the
				Medicare Supplement policyholders or certificate holders of one or more of its
				plans, to exchange during a specified period from his or her 1990 Standardized
				plan (as described in Rule
				10.09 of this regulation) to a 2010
				Standardized plan (as described in Rule
				10.09.1 of this regulation), the
				offer and subsequent exchange shall comply with the following requirements:
a. An issuer need not provide justification
				to the commissioner if the insured replaces a 1990 Standardized policy or
				certificate with an issue age rated 2010 Standardized policy or certificate at
				the insured's original issue age and duration. If an insured's policy or
				certificate to be replaced is priced on an issue age rate schedule at the time
				of such offer, the rate charged to the insured for the new exchanged policy
				shall recognize the policy reserve buildup, due to the pre-funding inherent in
				the use of an issue age rate basis, for the benefit of the insured. The method
				proposed to be used by an issuer must be filed with the commissioner according
				to the state's rate filing procedure.
b. The rating class of the new policy or
				certificate shall be the class closest to the insured's class of the replaced
				coverage.
c. An issuer may not
				apply new pre-existing condition limitations or a new incontestability period
				to the new policy for those benefits contained in the exchanged 1990
				Standardized policy or certificate of the insured, but may apply pre-existing
				condition limitations of no more than six (6) months to any added benefits
				contained in the new 2010 Standardized policy or certificate not contained in
				the exchanged policy.
d. The new
				policy or certificate shall be offered to all policyholders or certificate
				holders within a given plan, except where the offer or issue would be in
				violation of state or federal law.