New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter III - Policy and Certificate Provisions › Subchapter A - Life, Accident and Health Insurance › Part 58 - Minimum Standards For Form, Content And Sale Of Medicare Supplement And Medicare Select Insurance, Including Standards Of Full And Fair Disclosure › Section 58.2 - Rules relating to the standard medicare supplement benefit plans and the make-up of medicare supplement benefit plans issued for an effective date of coverage prior to june 1, 2010

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
				  General applicability. The following shall be applicable to Medicare supplement
				  insurance and Medicare select as defined in sections
				  52.11
				  and
				  52.14 
				  of this Title, respectively, and shall be in addition to other requirements of
				  this Part. Such rules shall apply to all Medicare supplement and Medicare
				  select policies and certificates issued with an effective date for coverage
				  prior to June 1, 2010 in this State. 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
				  plan standards. Benefit plan standards applicable to Medicare supplement
				  policies and certificates issued with an effective date for coverage on or
				  after June 1, 2010 are subject to the requirements of section
				  58.4 
				  of this Part.
(b) Standard Medicare
				  supplement benefit plans issued with an effective date for coverage prior to
				  June 1, 2010.
(1) No groups, packages or
				  combinations of Medicare supplement benefits other than those listed in this
				  section shall be offered for sale in this State, except as may be permitted in
				  subparagraph (6)(xi) of this subdivision.
(2) Where a nonprofit health service,
				  hospital service or medical expense indemnity corporation issues a subscriber
				  contract which does not include all of the benefits required for a plan of
				  Medicare supplement insurance, such contract must, in order to qualify as
				  Medicare supplement insurance, be issued in conjunction with another contract
				  including the remainder of the benefits required for a plan of Medicare
				  supplement insurance as prescribed in this section. In the alternative, two or
				  more of such corporations may act jointly and issue a single contract which
				  contains all of the benefits required for a plan of Medicare supplement
				  insurance.
(3) Benefit plans shall
				  be uniform in structure, language, designation and format to the standard
				  benefit plans "A'' through "L'' listed in subdivision (c) of this section and
				  conform to the definitions in section
				  58.1(a) 
				  of this Part. Each benefit plan shall be structured in accordance with the
				  format provided in paragraphs (5) and (6) of this subdivision and list the
				  benefits in the order shown in subdivision (c) of this section. For purposes of
				  this section, structure, language, and format means style, arrangement and
				  overall content of a benefit.
(4)
				  An issuer may use, in addition to the benefit plan designations required in
				  paragraph (3) of this subdivision, other designations to the extent permitted
				  by law or regulation.
(5) Benefit
				  plans A-J shall include the following basic "core'' benefits:
(i) coverage of Part A Medicare eligible
				  expenses for hospitalization to the extent not covered by Medicare from the
				  61st day through the 90th day in any Medicare benefit period;
(ii) coverage of Part A Medicare eligible
				  expenses incurred for hospitalization to the extent not covered by Medicare for
				  each Medicare lifetime inpatient reserve day used;
(iii) upon exhaustion of Medicare hospital
				  inpatient coverage, including the lifetime reserve days, coverage of 100
				  percent of the costs incurred for hospitalization expenses of the kind covered
				  by Medicare and recognized as medically necessary by Medicare, subject to a
				  lifetime maximum benefit of an additional 365 days. The issuer may enter into
				  reimbursement contracts with provider hospitals to stand in the place of
				  Medicare and to make payment for the hospitalization expenses at the applicable
				  prospective payment system (PPS) rate or other appropriate Medicare standard of
				  payment, so long as there continues to be no cost to the insured
				  person;
(iv) coverage under
				  Medicare Parts A and B for the reasonable cost of the first three pints of
				  blood (or equivalent quantities of packed red blood cells, as defined under
				  Federal regulations) unless replaced in accordance with Federal regulations;
				  and
(v) coverage for the
				  coinsurance amount, or in the case of hospital outpatient department services
				  paid under a prospective payment system, the copayment amount, of Medicare
				  eligible expenses under Part B regardless of hospital confinement, subject to
				  the Medicare Part B deductible.
(6) The following additional benefits shall
				  be included in Medicare supplement benefit plans "B'' through "J'' only, as
				  provided by subdivision (c) of this section.
(i) Medicare Part A deductible. Coverage for
				  all of the Medicare Part A inpatient hospital deductible amount per benefit
				  period.
(ii) Skilled nursing
				  facility care. Coverage for the actual billed charges up to the coinsurance
				  amount from the 21st day through the 100th day in a Medicare benefit period for
				  post hospital skilled nursing facility care eligible under Medicare Part
				  A.
(iii) Medicare Part B
				  deductible. Coverage for all of the Medicare Part B deductible amount per
				  calendar year regardless of hospital confinement.
(iv) 80 percent of the Medicare Part B excess
				  charges. Coverage for 80 percent of the difference between the actual Medicare
				  Part B charge as billed, not to exceed any charge limitation established by the
				  Medicare program or State law, and the Medicare-approved Part B
				  charge.
(v) 100 percent of the
				  Medicare Part B excess charges. Coverage for all of the difference between the
				  actual Medicare Part B charge as billed, not to exceed any charge limitation
				  established by the Medicare program or State law, and the Medicare-approved
				  Part B charge.
(vi) Basic
				  outpatient prescription drug benefit. Coverage for 50 percent of outpatient
				  prescription drug charges, after a $250 calendar year deductible, to a maximum
				  of $1,250 in benefits received by the insured per calendar year, to the extent
				  not covered by Medicare. The outpatient prescription drug benefit may be
				  included for sale or issuance in a Medicare supplement policy until January 1,
				  2006.
(vii) Extended outpatient
				  prescription drug benefit. Coverage for 50 percent of outpatient prescription
				  drug charges, after a $250 calendar year deductible to a maximum of $3,000 in
				  benefits received by the insured per calendar year, to the extent not covered
				  by Medicare. The outpatient prescription drug benefit may be included for sale
				  or issuance in a Medicare supplement policy until January 1, 2006.
(viii) Medically necessary emergency care in
				  a foreign country. Coverage to the extent not covered by Medicare for 80
				  percent of the billed charges for Medicare-eligible expenses for medically
				  necessary emergency hospital, physician and medical care received in a foreign
				  country, which care would have been covered by Medicare if provided in the
				  United States and which care began during the first 60 consecutive days of each
				  trip outside the United States, subject to a calendar year deductible of $250,
				  and a lifetime maximum benefit of $50,000. For purposes of this benefit,
				  emergency care shall mean care needed immediately because of an injury or an
				  illness of sudden and unexpected onset.
(ix) Preventive medical care benefit.
				  Coverage for the following preventive health services not covered by Medicare:
(a) An annual clinical preventive medical
				  history and physical examination that may include tests and services from
				  clause (b) of this subparagraph and patient education to address preventive
				  health care measures.
(b)
				  Preventive screening tests or preventive services, the selection and frequency
				  of which is determined to be medically appropriate by the attending physician.
Reimbursement shall be for the actual charges up to 100
					 percent of the Medicare-approved amount for each service, as if Medicare were
					 to cover the service as identified in American Medical Association Current
					 Procedural Terminology (AMACPT) codes, to a maximum of $120 annually under this
					 benefit. This benefit shall not include payment for any procedure covered by
					 Medicare.
(x)
				  At-home recovery benefit. Coverage for services to provide short term, at-home
				  assistance with activities of daily living for those recovering from an
				  illness, injury or surgery.
(a) For purposes
				  of this benefit, the following definitions shall apply:
(1) Activities of daily living include, but
				  are not limited to bathing, dressing, personal hygiene, transferring, eating,
				  ambulating, assistance with drugs that are normally self-administered, and
				  changing bandages or other dressings.
(2) Care provider means a duly qualified or
				  licensed home health aide or homemaker, personal care aide or nurse provided
				  through a licensed home health care agency or referred by a licensed referral
				  agency or licensed nurses' registry.
(3) Home shall mean any place used by the
				  insured as a place of residence, provided that such place would qualify as a
				  residence for home health care services covered by Medicare. A hospital or
				  skilled nursing facility shall not be considered the insured's place of
				  residence.
(4) At-home recovery
				  visit means the period of a visit required to provide at- home recovery care,
				  without limit on the duration of the visit, except each consecutive four hours
				  in a 24-hour period of services provided by a care provider is one
				  visit.
(b) Coverage
				  requirements and limitations:
(1) At-home
				  recovery services provided must be primarily services which assist in
				  activities of daily living.
(2) The
				  insured's attending physician must certify that the specific type and frequency
				  of at-home recovery services are necessary because of a condition for which a
				  home care plan of treatment was approved by Medicare.
(3) Coverage is limited to:
(i) no more than the number and type of
				  at-home recovery visits certified as necessary by the insured's attending
				  physician. The total number of at-home recovery visits shall not exceed the
				  number of Medicare approved home health care visits under a Medicare approved
				  home care plan of treatment;
(ii)
				  the actual charges for each visit up to a maximum reimbursement of $40 per
				  visit;
(iii) $1,600 per calendar
				  year;
(iv) seven visits in any one
				  week;
(v) care furnished on a
				  visiting basis in the insured's home;
(vi) services provided by a care provider as
				  defined in this section;
(vii)
				  at-home recovery visits while the insured is covered under the policy or
				  certificate and not otherwise excluded; and
(viii) at-home recovery visits received
				  during the period the insured is receiving Medicare approved home care services
				  or no more than eight weeks after the service date of the last Medicare
				  approved home health care visit.
(c) Coverage is excluded for:
(1) home care visits paid for by Medicare or
				  other government programs; and
(2)
				  care provided by family members, unpaid volunteers or providers who are not
				  care providers.
(xi) New or innovative benefits. An issuer
				  may, with the prior approval of the superintendent, offer policies or
				  certificates with new or innovative benefits in addition to the benefits
				  provided in a policy or certificate that otherwise complies with the applicable
				  standards. Such new or innovative benefits may include benefits that are
				  appropriate to Medicare supplement insurance, new or innovative, not otherwise
				  available, cost-effective, and offered in a manner which is consistent with the
				  goal of simplification of Medicare supplement policies. After December 31,
				  2005, the innovative benefit shall not include an outpatient prescription drug
				  benefit.
(7)
(i) Every issuer shall make available both
				  standardized Medicare supplement insurance benefit plans "A'' and "B,'' as
				  defined in paragraphs (c)(1) and (2) of this section, to each prospective
				  policyholder and certificateholder. An issuer may make available to prospective
				  policyholders and certificateholders any of the other Medicare supplement
				  insurance benefit plans permitted by this section in addition to benefit plans
				  "A" and "B,'' but not in lieu thereof.
(ii) Every issuer shall permit its
				  policyholders and certificateholders to terminate existing coverage and replace
				  it with any other Medicare supplement insurance benefit plan then being made
				  available to prospective policyholders and certificateholders by the issuer. An
				  issuer may limit changes in coverage initiated by a policyholder or
				  certificateholder to an anniversary date or other regular interval, so long as
				  the interval is not less than once every 12 months.