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 19-3-10.08.1

Current through June 25, 2024
Benefit Standards For 2010 Standardized Medicare Supplement
				  Benefit Plan Policies Or Certificates Issued For Delivery With An Effective
				  Date For Coverage On Or After June 1, 2010
The following standards are applicable to all Medicare
				  supplement policies or certificates delivered or issued for delivery in this
				  state with an effective date for delivery 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 for coverage prior to June 1, 2010 remain subject to the
				  requirements of Miss. Code Ann. §
									83-9-101
				  to 115, and this regulation.
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
				10.08.1 A(5)(e) of this regulation, 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 10.08.1 A(5)(c)
				of this regulation; 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.
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; 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.