Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 37 - Medicare Supplement Insurance › Rule 191-37.8 - 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 (2010 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 with an effective date for coverage on or after June 1, 2010. No policy
				  or certificate was to be advertised, solicited, delivered, or issued for
				  delivery in this state as a Medicare supplement policy or certificate during
				  that time period unless it complied with the benefit standards set forth in
				  this rule. 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 before June 1, 2010,
				  remain subject to the requirements of rule
				  191-376. (514D) or
				  191-37.7(514D).
(1)
General
				standards.
The following standards apply to 2010 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 37.8(5)
				and rule 191-3720. (514D).
b.
Uniformity and
				conformity.
All 2010 plans shall be uniform in structure, language,
				designation and format to the standardized benefit plans listed in subrule
				37.8(4), and shall conform to the definitions in rules
				191-373. (514D) and
				191-374. (514D). Each benefit
				plan shall be structured in accordance with the format provided in subrules
				37.8(2), 37.8(3) and 37.8(4), or in the case of Plan K or L, each benefit plan
				shall be structured in accordance with the format provided in paragraph
				37.8(4)
"h"
or
"i."
Each plan shall list the
				benefits in the order shown. 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 37.8(1)
"b,"
other designations to the extent permitted by law.
d.
Preexisting conditions.
A
				2010 plan shall not exclude or limit benefits for losses incurred more than six
				months from the effective date of coverage because the losses involved a
				preexisting condition. The 2010 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 2010 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 2010 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 Medicare deductible, copayment, or
				coinsurance amounts. Premiums may be modified to correspond with such
				changes.
g.
Termination of
				coverage of spouse.
No 2010 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 named insured or group member, other than the
				nonpayment of premium.
h.
Guaranteed renew ability.
Each 2010 plan shall be guaranteed
				renewable.
(1) The issuer shall not cancel or
				nonrenew the policy or certificate solely on the ground of health status of the
				covered individual.
(2) The issuer
				shall not cancel or nonrenew the 2010 plan for any reason other than nonpayment
				of premium or material misrepresentation.
(3) If a group 2010 plan is terminated by the
				group policyholder and is not replaced as provided under subparagraph
				37.8(1)
"h"
(5), the issuer shall offer covered individuals a
				conversion opportunity to an individual 2010 plan which, at the option of the
				covered individual, either:
1. Provides for
				continuation of the benefits contained in the group 2010 plan; or
2. Provides for benefits that otherwise meet
				the requirements of this subrule.
(4) If a covered individual under a group
				2010 plan terminates membership in the group, the issuer shall:
1. Offer the covered individual the
				conversion opportunity described in subparagraph
				37.8(1)
"h"
(3); or
2. At the option of the group policyholder,
				offer the covered individual continuation of coverage under the group 2010
				plan.
(5) If a group
				2010 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 2010 plan on
				the effective date of termination of the replaced group 2010 plan. Coverage
				under the replacement group Medicare supplement policy shall not result in any
				exclusion for any covered individual's preexisting conditions that would have
				been covered under the replaced group 2010 plan.
i.
Termination involving continuous
				loss.
Termination of a 2010 plan policy or certificate shall be
				without prejudice to any continuous loss which commenced while the policy or
				certificate was in force, but the extension of benefits beyond the period
				during which the policy or certificate was in force may be conditioned upon the
				continuous total disability of the covered individual, limited to the duration
				of the policy or certificate 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 2010 plan shall provide that benefits
				and premiums under the policy or certificate 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 the policy or certificate within 90 days
				after the date the covered individual becomes entitled to assistance.
(2) If such suspension occurs and if the
				covered individual loses entitlement to medical assistance, the policy or
				certificate shall be automatically reinstituted effective as of the date of
				termination of entitlement if the covered individual provides notice of loss of
				entitlement within 90 days after the date of loss and pays the premium
				attributable to the period, effective as of the date of termination of
				entitlement.
(3) Each 2010 plan
				shall provide that benefits and premiums under the 2010 plan shall be suspended
				(for any period that may be 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 2010 plan policy or certificate 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 the loss and pays the premium attributable to the period,
				effective as of the date of termination of such entitlement.
(4) Reinstitution of coverage as described in
				subparagraphs 37.8(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; 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.