Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 13 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 365:10-5-127.1 - Benefit standards for 2010 standardized Medicare supplement benefit plan policies or certificates issued for delivery on or after June 1, 2010

Current through Vol. 41, No. 20, July 1, 2024
(a)
Benefit Standards.
The
				  following standards are applicable to all Medicare supplement policies or
				  certificates delivered or issued for delivery in this state 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 before June 1, 2010 remain subject to the
				  requirements of O.A.C.
				  365:10-5-126 and
				  365:10-5-127.
(b)
General Standards.
The
				  following standards apply to Medicare supplement policies and certificates and
				  are in addition to all other requirements of this regulation.
(1)
Preexisting conditions.
A
				  Medicare supplement policy or certificate shall not exclude or limit benefits
				  for losses incurred more than six (6) 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 (6) months before the effective date of
				  coverage.
(2)
Sickness and
				  accidents.
A Medicare supplement policy or certificate shall not
				  indemnify against losses resulting from sickness on a different basis than
				  losses resulting from accidents.
(3)
Benefits designed to cover cost
				  sharing amounts under Medicare.
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 amount and copayment factors. Premiums may
				  be modified to correspond with such changes.
(4)
Termination of coverage of a
				  spouse.
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.
(5)
Guaranteed renewable.
Each Medicare supplement policy shall be
				  guaranteed renewable.
(A) The issuer shall
				  not cancel or nonrenew the policy solely on the ground of health status of the
				  individual.
(B) The issuer shall
				  not cancel or nonrenew the policy for any reason other than nonpayment of
				  premium or material misrepresentation.
(C) If the Medicare supplement policy is
				  terminated by the group policyholder and is not replaced as provided under
				  O.A.C. 365:10-5-127.1(b)(5)(E) of this regulation, the issuer shall offer
				  certificateholders an individual Medicare supplement policy which (at the
				  option of the certificateholder):
(i) Provides
				  for continuation of the benefits contained in the group policy; or
(ii) Provides for benefits that otherwise
				  meet the requirements of this Subsection.
(D) If an individual is a certificateholder
				  in a group Medicare supplement policy and the individual terminates membership
				  in the group, the issuer shall
(i) Offer the
				  certificateholder the conversion opportunity described in O.A.C.
				  356:10-7-127.1(b)(5)(C); or
(ii) At
				  the option of the group policyholder, offer the certificateholder continuation
				  of coverage under the group policy.
(E) 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.
(6)
Continuous
				  loss.
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.
(7)
Suspension.
(A) 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 twenty-four (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 ninety (90) days after the date the individual
				  becomes entitled to assistance.
(B)
				  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.
(C) 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 ninety (90) days after the date of the loss.
(D) Reinstitution of coverages as described
				  in Subparagraphs (B) and (C):
(i) Shall not
				  provide for any waiting period with respect to treatment of preexisting
				  conditions;
(ii) Shall provide for
				  resumption of coverage that is substantially equivalent to coverage in effect
				  before the date of suspension; and
(iii) 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.