Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 37 - Medicare Supplement Insurance › Rule 191-37.7 - 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 for Coverage Prior to June 1, 2010 (1990 plans)

Current through Register Vol. 47, No. 3, July 24, 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 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. No issuer may
				  offer any prestandardized Medicare supplement benefit plan for sale on or after
				  January 1, 1992. Benefit standards applicable to Medicare supplement policies
				  and certificates issued before January 1, 1992, remain subject to the
				  requirements of rule 191-376. (514D).
(1)
General standards.
The
				following standards apply to 1990 plans and are in addition to all other
				requirements of this chapter.
a.
Combinations of benefits other than standard not allowed.
No
				groups, packages or combinations of Medicare supplement benefits other than
				those listed in this rule shall be offered for sale in this state, except as
				may be permitted in subrule 37.7(6) and in rule
				191-3720. (514D).
b.
Uniformity and
				conformity.
All 1990 plans shall be uniform in structure, language,
				designation and format to the standardized Medicare supplement benefit plans A
				through L listed in subrule 37.7(4) and shall conform to the definitions in
				rules 191-373. (514D) and
				191-374. (514D). Each benefit
				shall be structured in accordance with the format provided in this rule and
				list the benefits in the order shown in this rule. For purposes of this rule,
				"structure, language, and format" means style, arrangement and overall content
				of a benefit.
c.
Other
				designations may be used.
An issuer may use, in addition to the
				benefit plan designations required in paragraph 37.7(1)
"b,"
other designations to the extent permitted by law.
d.
Preexisting conditions.
A
				1990 plan shall not exclude or limit benefits for losses incurred more than six
				months from the effective date of coverage because the claim involved a
				preexisting condition. The 1990 plan 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 months
				before the effective date of coverage.
e.
Sickness same as
				accident.
A 1990 plan shall not indemnify against losses resulting
				from sickness on a different basis than losses resulting from accidents.
f.
Automatic change of cost
				sharing.
A 1990 plan shall provide that benefits designed to cover
				cost-sharing amounts under Medicare will be changed automatically to coincide
				with any changes in the applicable deductible, copayment, or coinsurance
				amounts set by Medicare. Premiums may be modified to correspond with such
				changes.
g.
Termination of
				coverage of spouse.
No 1990 plan 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.
h.
Guaranteed
				renew ability.
Each 1990 plan shall be guaranteed renewable.
(1) The issuer shall not cancel or nonrenew a
				1990 plan solely on the ground of health status of the covered
				individual.
(2) The issuer shall
				not cancel or nonrenew a 1990 plan for any reason other than nonpayment of
				premium or material misrepresentation.
(3) If the 1990 plan is terminated by the
				group policyholder and is not replaced as provided under subparagraph
				37.7(1)
"h"
(5), the issuer shall offer to the covered
				individual a conversion opportunity of an individual Medicare supplement policy
				which, at the option of the covered individual, either:
1. Provides for continuation of the benefits
				contained in the group 1990 plan; or
2. Provides for such benefits as otherwise
				meet the requirements of this subrule.
(4) If a covered individual under a group
				1990 plan terminates membership in the group, the issuer shall either:
1. Offer the covered individual the
				conversion opportunity described in subparagraph
				37.7(1)
"h"
(3); or
2. At the option of the group policyholder,
				offer the covered individual continuation of coverage under the group Medicare
				supplement policy.
(5)
				If a group 1990 plan is replaced by another group Medicare supplement policy
				purchased by the same group policyholder, the issuer of the replacement group
				Medicare supplement policy shall offer coverage under the replacement group
				Medicare supplement policy to all covered individuals of the replaced group
				1990 plan effective on the date of termination of the replaced group 1990 plan.
				Coverage under the replacement group Medicare supplement policy shall not
				result in any exclusion of any covered individual's preexisting conditions that
				would have been covered under the replaced group 1990 plan.
(6) If a 1990 plan eliminates an outpatient
				prescription drug benefit as a result of requirements imposed by the MMA, the
				modified 1990 plan shall be deemed to satisfy the guaranteed renewal
				requirements of this paragraph.
i.
Termination involving continuous
				loss.
Termination of a 1990 plan shall be without prejudice to any
				continuous loss which commenced while the 1990 plan was in force, but the
				extension of benefits beyond the period during which the 1990 plan was in force
				may be conditioned upon the continuous total disability of the covered
				individual, limited to the duration of the 1990 plan 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.
j.
Suspension for Title XIX
				coverage.
(1) A 1990 plan shall
				provide that benefits and premiums under the 1990 plan shall be suspended at
				the request of the covered individual for the period (not to exceed 24 months)
				in which the covered individual has applied for and is determined to be
				entitled to medical assistance under Title XIX of the Social Security Act, but
				only if the covered individual notifies the issuer of such 1990 plan within 90
				days after the date the covered individual becomes entitled to such
				assistance.
(2) If such suspension
				occurs and if the covered individual loses entitlement to such medical
				assistance, such 1990 plan shall be automatically reinstituted (effective as of
				the date of termination of such entitlement) if the covered individual provides
				notice of loss of such entitlement within 90 days after the date of such loss
				and pays the premium attributable to the period, effective as of the date of
				termination of such entitlement.
(3) Each 1990 plan shall provide that
				benefits and premiums under the 1990 plan shall be suspended for the period
				provided by federal regulation at the request of the covered individual if the
				covered individual 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)(l)(A)(v) of the Social Security Act. If suspension occurs and if the
				covered individual loses coverage under the group health plan, the 1990 plan
				shall be automatically reinstituted effective as of the date of loss of
				coverage if the covered individual provides notice to the issuer of loss of
				coverage within 90 days after the date of such 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 coverage as described in
				subparagraphs 37.7(1)
"j"
(2) and (3):
1. Shall not provide for any waiting period
				with respect to treatment of preexisting conditions;
2. Shall provide for resumption of coverage
				that is substantially equivalent to coverage in effect before the date of
				suspension. If the suspended 1990 plan provided coverage for outpatient
				prescription drugs, reinstitution of the 1990 plan 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
3. Shall provide for classification of
				premiums on terms at least as favorable to the covered individual as the
				premium classification terms that would have applied to the covered individual
				had the coverage not been suspended.
k.
Exchange of 1990 plan to 2010
				plan.
If an issuer makes a written offer to a covered individual
				covered by one or more of the issuer's 1990 plans (as described in this rule)
				to allow, during a specified period, the covered individual to exchange
				coverage from the covered individual's 1990 plan (as described in this rule) to
				a 2010 plan (as described in rule
				191-378. (514D)), the offer and
				subsequent exchange shall comply with the following requirements:
(1) An issuer need not provide justification
				to the commissioner or comply with 191-Chapter 16 or rule
				191-3727. (514D) if the covered
				individual exchanges a 1990 plan policy or certificate for an issue-age-rated
				2010 plan policy or certificate using the same issue age and duration as was
				used for the covered individual's 1990 plan policy or certificate to be
				exchanged. If a covered individual's 1990 plan policy or certificate to be
				exchanged is priced on an issue-age-rate schedule at the time of such offer,
				the rate charged to the covered individual for the exchanged 2010 plan policy
				or certificate shall recognize the policy reserve buildup, due to the
				prefunding inherent in the use of an issue-age-rate basis, for the benefit of
				the covered individual. The rating method proposed to be used by an issuer must
				be filed with the commissioner pursuant to rule
				191-3724. (514D).
(2) The rating class of the new exchanged
				2010 plan policy or certificate shall be the class closest to the covered
				individual's rating class of the exchanged 1990 plan.
(3) An issuer may not apply new preexisting
				condition limitations or a new incontestability period to the covered
				individual's exchanged 2010 plan for those benefits contained in the exchanged
				1990 plan, but may apply preexisting condition limitations of no more than six
				months to any added benefits contained in the exchanged 2010 plan that were not
				contained in the exchanged 1990 plan.
(4) The exchanged 2010 plan shall be offered
				to all covered individuals within a given 1990 plan, except where the offer or
				issue would be in violation of state or federal law.