Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 71.00 - Medicare Supplement Insurance To Facilitate The Implementation Of M.G.L. c. 176k And Section 1882 Of The Federal Social Security Act › Section 71.09 - New or Innovative Benefits

Current through Register 1525, July 5, 2024
An Issuer of Medicare Supplement Insurance may, with the prior
				approval of the Commissioner, offer Medicare Supplement Insurance Policies with
				new or innovative benefits described in 211 CMR 71.09 in addition to the
				benefits provided in a Policy that otherwise complies with the applicable
				standards set forth in
				211 CMR 71.00. The new or
				innovative benefits may include benefits that are appropriate to Medicare
				Supplement Insurance, new or innovative, not otherwise available,
				cost-effective, and offered in a manner which is consistent with the goal of
				simplification of Medicare Supplement Insurance Policies. Only those new and
				innovative benefits specified in 211 CMR 71.09 and any other new or innovative
				benefits approved by the Commissioner may be so offered. Nothing in 211 CMR
				71.09 prohibits an Issuer offering a Policy with new or innovative benefits
				consistent with 211 CMR 71.09 from also providing a Policy of the same Medicare
				Supplement option type without the new or innovative benefit. Notwithstanding
				the provisions of any other section, a Medicare Supplement Insurance Policy
				with benefits for outpatient prescription drugs, including such benefits
				provided through Alternate Innovative Benefits Riders shall not be issued after
				December 31, 2005, but coverage in effect on December 31, 2005 shall be
				renewed, except as identified in
				211 CMR
				71.07(5).
(1)
Individual Case
			 Management
. Issuers providing Medicare Supplement Insurance may
			 provide coverage for services in addition to the benefits required by the
			 Commissioner for the applicable Medicare Supplement Core Policy, Medicare
			 Supplement 1 Policy, Medicare Supplement 1A Policy, or Medicare Supplement 2
			 Policy as part of an individual case management program. Such program must be
			 approved by the Commissioner in advance. Such individual case management
			 program may be established by the Issuer pursuant to a plan of care agreed to
			 by the Insured and the attending physician and approved under the Issuer's
			 individual case management program.
(2)
Outpatient Prescription Drug
			 Benefits
. In providing the Outpatient Prescription Drug benefits
			 in a Medicare Supplement 2 Insurance Policy, an Issuer may limit benefits to
			 those received from providers with which it has an agreement, provided that
			 such limitation does not significantly reduce the availability of benefits
			 under the Policy; and provided further, that any limitation or exclusion of a
			 provider, and any such agreement, are in accordance with M.G.L. c. 176D, §
			 3B. For the purposes of 211 CMR 71.09(2), "Outpatient Prescription Drugs"
			 includes insulin, as well as the needles, syringes, pumps and pump supplies
			 necessary for the administration of insulin and blood sugar level testing
			 equipment and supplies for use at home; drugs provided by a home infusion
			 therapy provider; and drugs used on an off-label basis for the treatment of
			 cancer or HIV/AIDS and medically necessary services associated with the
			 administration of such drugs as required by M.G.L. c. 175, § 47K; M.G.L.
			 c. 175, § 47L; M.G.L. c. 176A, § 8N; or M.G.L. c. 176B, § 4N, or
			 by M.G.L. c. 175, § 47O; M.G.L. c. 175, § 47P; M.G.L. c. 176A, §
			 8Q (as added by St. 1996, c. 450, § 222); or by M.G.L. c. 176B, § 4P
			 (as added by St. 1994, c. 60, § 146), and drugs and devices for hormone
			 replacement therapy for peri- and post-menopausal women and for outpatient
			 prescription contraceptive drugs or devices as required by M.G.L. c. 175,
			 § 47W; M.G.L. c. 176A, § 8W or M.G.L. c. 176B, § 4W (as added by
			 St. 2002, c. 49).
(3)
Mail Service Prescription Drug Program
. Issuers
			 providing Medicare Supplement Insurance Policies may provide coverage for a
			 mail service prescription drug program for Outpatient Prescription Drugs for
			 which federal law requires a prescription in addition to the benefits required
			 by the Commissioner for a Medicare Supplement 2 Insurance Policy. The benefit
			 must be approved by the Commissioner in advance; provided however, that the
			 Insured shall only be charged a copayment and the Insured's copayments for
			 Outpatient Prescription Drugs shall be either:
(a) no higher than $8 for each generic
			 prescription or refill and no higher than $15 for each brand name prescription
			 or refill; or
(b) no higher than
			 $10 for each generic or brand name prescription or refill; and provided,
			 further, that each such prescription or refill shall contain a minimum of 21
			 days' and a maximum of 90 days' supply.
Nothing in 211 CMR 71.09(3) shall be construed to prevent such
				an Issuer from basing payment on allowed charges rather than on charges or
				limiting benefits to those received from providers with whom they have an
				agreement; provided that such limitation does not significantly reduce the
				availability of benefits under the Policy; and provided further, that any
				limitation or exclusion of a provider, and any such agreement, are in
				accordance with M.G.L. c. 176D, § 3B. For the purposes of 211 CMR
				71.09(3), "Outpatient Prescription Drugs" includes insulin, as well as the
				needles, syringes, pumps and pump supplies necessary for the administration of
				insulin and blood sugar level testing equipment and supplies for use at home;
				drugs provided by a home infusion therapy provider; and drugs used on an
				off-label basis for the treatment of cancer or HIV/AIDS and medically necessary
				services associated with the administration of such drugs as required by M.G.L.
				c. 175, § 47K; M.G.L. c. 175, § 47L; M.G.L. c. 176A, § 8N; or
				M.G.L. c. 176B, § 4N; or by M.G.L. c. 175, § 47O; M.G.L. c. 175,
				§ 47P; M.G.L. c. 176A, § 8Q (as added by St. 1996, c. 450, §
				222); or by M.G.L. c. 176B, § 4P (as added by St. 1994, c. 60, §
				146); and drugs and devices for hormone replacement therapy for peri- and
				post-menopausal women and for outpatient prescription contraceptive drugs or
				devices as required by M.G.L. c. 175, § 47W; M.G.L. c. 176A, § 8W or
				M.G.L. c. 176B, § 4W (as added by St. 2002, c. 49, §§ 4 and
				5).