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 58.4 - Rules relating to content of forms for medicare supplement insurance policies and certificates issued with an effective date for coverage on or after 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 section
				  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 on
				  or after 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 prior to
				  June 1, 2010 remain subject to the requirements of section
				  58.2 
				  of this Part.
(b) Standard Medicare
				  supplement benefit plans issued with an effective date for coverage on or after
				  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)(vii) 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", "B", "C", "D", "F ", high deductible "F+", "G", high
				  deductible "G+", "K", "L", "M", and "N'' listed in subdivision (c) of this
				  section and conform to the defini- tions 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) Standards
				  for Basic "Core" Benefits Common to Medicare Supplement Insurance Benefit Plans
				  "A", "B", "C", "D", "F", high deductible "F+", "G", high deductible "G+", "M"
				  and "N". Every issuer of Medicare supplement insurance benefit plans shall make
				  available a policy or certificate including only the following basic "core"
				  package of benefits to each prospective insured.
(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.
(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.
(vi) Hospice care. Coverage of cost sharing
				  for all Part A Medicare eligible hospice care and respite care
				  expenses.
(6) Standards
				  for Additional Benefits. The following additional benefits shall be included in
				  Medicare supplement benefit Plans "B", "C", "D", "F", high deductible "F+", "G", high deductible "G+", "M" and "N" as provided by subdivision (c) of this
				  section.
(i) Medicare Part A deductible.
				  Coverage for 100 percent of the Medicare Part A inpatient hospital deductible
				  amount per benefit period.
(ii)
				  Medicare Part A deductible. Coverage for 50 percent of the Medicare Part A
				  inpatient hospital deductible amount per benefit period.
(iii) 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.
(iv) Medicare Part B deductible. Coverage for
				  100 percent of the Medicare Part B deductible amount per calendar year
				  regardless of hospital confinement.
(v) 100 Percent of the Medicare Part B excess
				  charges. Coverage for all of the difference between the actual Medicare Part B
				  charges as billed, not to exceed any charge limitation established by the
				  Medicare program or State law, and the Medicare-approved Part B
				  charge.
(vi) 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.
(vii) 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 standardized
				  benefits provided in a policy or certificate that otherwise complies with the
				  applicable standards. The new or innovative benefits shall include only
				  benefits that are appropriate to Medicare supplement insurance, are new or
				  innovative, are not otherwise available, and are cost-effective. Approval of
				  new or innovative benefits must not adversely impact the goal of Medicare
				  supplement simplification. New or innovative benefits shall not include an
				  outpatient prescription drug benefit. New or innovative benefits shall not be
				  used to change or reduce benefits, including a change of any cost-sharing
				  provision, in any standardized plan.
(7)
(i)
				  Every issuer shall [also] make available both standardized Medicare supplement
				  insurance benefit plans "A" and "B," as defined in subdivision (c)(1) and (2)
				  of this section, to each prospective policyholder and
				  certificateholder.
(ii) The issuer
				  shall make available to those individuals who first become eligible for
				  Medicare before January 1, 2020 based on age or disability standardized
				  Medicare supplement benefit plans "C", as described in subdivision (c)(3) of
				  this section, or "F" as described in subdivision (c)(5) of this section. 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".
(iii) The issuer shall make available to
				  those individuals who first become eligible for Medicare due to age or
				  disability on or after January 1, 2020 standardized Medicare supplement benefit
				  plans "D", as described in subdivision (c)(4) of this section or "G" as
				  described in subdivision (c)(7) of this section. An issuer may make available
				  to prospective policyholders and certificateholders any of the other Medicare
				  supplement insurance benefit plans permitted by this section in additio n to
				  benefit plans "A" and "B" and either "D" or "G", but not in lieu
				  thereof.
(iv) Every issuer shall
				  permit its policyholders and certificate- holders to terminate existing
				  coverage and replace it with a ny other Medicare supplement insurance benefit
				  plan then being made available to prospective policyholders and
				  certificateholders by the is suer. An issuer may limit changes in coverage
				  initiated by a policyholder or certificate- holder to an anniversary date or
				  other regular interval, so long as the interval is not less than once every 12
				  months.