Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 5 - Regulation 33-Medicare Supplement Insurance Minimum Standards › Section XIII-515 - Benefit Standards for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or After July 20, 1992 and with an Effective Date for Coverage Prior to June 1, 2010

Current through Register Vol. 50, No. 6, June 20, 2024
A. The following
				standards are applicable to all Medicare supplement policies or certificates
				delivered or issued for delivery in this state on or after July 20, 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.
1. General
				Standards. The following standards apply to Medicare supplement policies and
				certificates and are in addition to all other requirements of this regulation.
a. A Medicare supplement policy or
				certificate shall not exclude or limit benefits for losses incurred more than
				six 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
				months before the effective date of coverage.
b. A Medicare supplement policy or
				certificate shall not indemnify against losses resulting from sickness on a
				different basis than losses resulting from accidents.
c. 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.
d. 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.
e. Each Medicare supplement policy shall be
				guaranteed renewable.
i. The issuer shall not
				cancel or nonrenew the policy solely on the ground of health status of the
				individual.
ii. The issuer shall
				not cancel or nonrenew the policy for any reason other than nonpayment of
				premium or material misrepresentation.
iii. If the Medicare supplement policy is
				terminated by the group policyholder and is not replaced as provided under
				§515. A.1.e v, the issuer shall offer certificateholders an individual Medicare
				supplement policy which (at the option of the certificateholder):
(a). provides for continuation of the
				benefits contained in the group policy; or
(b). provides for benefits that otherwise
				meet the requirements of this Subsection.
iv. If an individual is a certificateholder
				in a group Medicare supplement policy and the individual terminates membership
				in the group, the issuer shall:
(a). offer the
				certificateholder the conversion opportunity described in §515. A.1.e iii;
				or
(b). at the option of the group
				policyholder, offer the certificateholder continuation of coverage under the
				group policy.
v. 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.
vi. 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.
f. 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.
g.
i. 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
				certificateholder for the period (not to exceed 24 months), or upon discovery
				by the insurer that the policyholder or certificateholder 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 certificateholder notifies
				the issuer of the policy or certificate within 90 days after the date the
				individual becomes entitled to assistance.
ii. If suspension occurs and if the
				policyholder or certificateholder loses entitlement to medical assistance, the
				policy or certificate shall be automatically reinstituted (effective as of the
				date of termination of such entitlement) as of the termination of entitlement
				if the policyholder or certificateholder 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.
iii. 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 certificateholder 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 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.
iv. Reinstitution of coverage as described in
				Clauses g.ii and iii:
(a). shall not provide
				for any waiting period with respect to treatment of preexisting
				conditions;
(b). 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
(c). shall provide for classification of
				premiums on terms at least as favorable to the policyholder or
				certificateholder as the premium classification terms that would have applied
				to the policyholder or certificateholder had the coverage not been
				suspended.
h.
i. If an issuer makes a written offer to the
				Medicare Supplement policyholders or certificateholders of one or more of its
				plans, to exchange during a specified period from his or her 1990 Standardized
				plan (as described in
				§520 of this regulation) to a 2010
				Standardized plan (as described in
				§521 of this regulation), the offer and
				subsequent exchange shall comply with the following requirements:
ii. 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 in
				accordance with rate filing procedures prescribed by the
				commissioner.
iii. The rating class
				of the new policy or certificate shall be the class closest to the insured's
				class of the replaced coverage.
iv.
				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 months to any added
				benefits contained in the new 2010 Standardized policy or certificate not
				contained in the exchanged policy.
v. The new policy or certificate shall be
				offered to all policyholders or certificateholders within a given plan, except
				where the offer or issue would be in violation of state or federal
				law.