North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-01.1 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 45-06-01.1-06.1 - 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 Supplement No. 393, July, 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 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 sections 45-06-01.1-06 and 45-06-01.1-07.
1. General standards. The following standards
				apply to Medicare supplement policies and certificates and are in addition to
				all other requirements of this chapter:
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, copayment, 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.
(1) The issuer shall not
				cancel or nonrenew the policy solely on the ground of health status of the
				individual.
(2) The issuer shall
				not cancel or nonrenew the policy for any reason other than nonpayment of
				premium or material misrepresentation.
(3) If the Medicare supplement policy is
				terminated by the group policyholder and is not replaced as provided under
				paragraph 5, the issuer shall offer certificate holders an individual Medicare
				supplement policy which at the option of the certificate holder:
(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.
(4) If an individual is a certificate holder
				in a group Medicare supplement policy and the individual terminates membership
				in the group the issuer shall:
(a) Offer the
				certificate holder the conversion opportunity described in paragraph 3;
				or
(b) At the option of the group
				policyholder, offer the certificate holder continuation of coverage under the
				group policy.
(5) 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.
(1) 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 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 days after the date the individual becomes
				entitled to assistance. Upon receipt of timely notice, the issuer shall return
				to the policyholder or certificate holder that portion of the premium
				attributable to the period of medical assistance eligibility subject to
				adjustment for paid claims.
(2) 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 if the policyholder or certificate holder provides notice of loss
				of entitlement within ninety 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 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 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.
(4) Reinstitution of coverages as described
				in paragraphs 2 and 3:
(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 certificate
				holder as the premium classification terms that would have applied to the
				policyholder or certificate holder had the coverage not been
				suspended.