Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 5 - Regulation 33-Medicare Supplement Insurance Minimum Standards › Section XIII-516 - 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

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 with an effective
				date for coverage 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 §510,
				§515, §520, and §525
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 non-renew the policy solely on the ground of health status of the
				individual.
ii. The issuer shall
				not cancel or non-renew 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
				§516. A.1.e.v of this regulation, 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 §516. A.1.e iii. of
				this regulation; 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.
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)
				in which 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
				entitlement) as of the termination of entitlement if the policyholder or
				certificateholder 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.
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.
iv. Reinstitution of coverages as described
				in Subparagraphs (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; 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.