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 - Benefit standards for 1990 standardized medicare supplement benefit plan policies or certificates issued for delivery on or after January 1,1992, and with an effective date for coverage prior to 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 on or after January 1, 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 rule:
a. A medicare supplement policy or
				certificate may 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 may not indemnify against losses resulting from sickness on a
				different basis than losses resulting from accidents.
c. A medicare supplement policy or
				certificate must 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 may 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 must be
				guaranteed renewable:
(1) The issuer may not
				cancel or nonrenew the policy solely on the ground of health status of the
				individual.
(2) The issuer may 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 must 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 must:
(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 must offer coverage to all persons covered under the old
				group policy on its date of termination. Coverage under the new policy may not
				result in any exclusion for preexisting conditions that would have been covered
				under the group policy being replaced.
(6) 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 must 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) Amedicaresupplement policy or certificate
				must provide that
benefits and premiums under the policy or certificate must
				  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 [
				  42 U.S.C.
				  1396, et seq.], 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 such coverage, if the policyholder provides notice of loss
				of coverage within ninety days after the date of such loss and pays the premium
				due from that date.
(4)
				Reinstitution of coverage as described in paragraphs 2 and 3:
(a) May not provide for any waiting period
				with respect to treatment of preexisting conditions;
(b) Must 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) Must 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.
h. If an
				issuer makes a written offer to the medicare supplement policyholders or
				certificate holders of one or more of its plans, to exchange during a specified
				period from the 1990 standardized plan as described in section
				45-06-01.1-07 to a 2010
				standardized plan as described in section
				45-06-01.1-07.1, the offer and
				subsequent exchange shall comply with the following requirements:
(1) 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 prefunding 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.
(2) The rating class of the new
				policy or certificate shall be the class closest to the insured's class of the
				replaced coverage.
(3) An issuer
				may not apply new preexisting 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 preexisting
				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.
(4) The new
				policy or certificate shall be offered to all policyholders or certificate
				holders within a given plan, except where the offer or issue would be in
				violation of state or federal law.