New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 23 - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT COVERAGE › Section 11:4-23.8 - Minimum benefit standards for 1990 Standardized Medicare supplement benefit plan policies and certificates delivered or issued for delivery on or after January 4, 1993 and with an effective date for coverage prior to June 1, 2010

Current through Register Vol. 56, No. 14, July 15, 2024
(a) No policy or certificate shall be advertised, solicited, delivered or issued for delivery in this State as a Medicare supplement policy on or after January 4, 1993 and with an effective date for coverage prior to June 1, 2010 unless it complies with the standards of 11:4-23.6 and the benefit standards set forth below.
(b) Medicare supplement policies shall be guaranteed renewable.
(c) 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 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 ( 42 U.S.C. §
										1396v through end), but only if the policyholder or certificateholder notifies the issuer of the policy or certificate within 90 days after the date that the individual becomes entitled to that assistance.
1. If suspension occurs and if the policyholder or certificateholder loses entitlement to Title XIX medical assistance, the policy or certificate shall be automatically reinstituted (effective as of the date of the termination of the entitlement) if the policyholder or certificateholder provides notice of their loss of the entitlement to the Title XIX assistance within 90 days after the date of that loss and the policyholder or certificateholder pays the premium attributable to the period subsequent to the date of the termination of the entitlement.
2. 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, 42 U.S.C. §
											426(b), and is covered under a group health plan (as defined in Section 1862(b)(1)(A)(v) of the Social Security Act, 42 U.S.C. §
											1395y(b)(1)(A)(v) ). 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 90 days after the date of the loss and pays the premium attributable to the period from the date of the termination of their enrollment in the group health plan.
3. Reinstitution of coverage as described in (c)1 and 2 above shall:
i. Not impose any waiting period with respect to treatment of preexisting conditions;
ii. Provide for resumption of coverage that is substantially equivalent to the coverage that was in effect before the date of the 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
iii. 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.
4. If a carrier makes a written offer to the Medicare supplement policyholders or certificateholders of one or more of its plans to exchange, during a specified period, from his or her 1990 Standardized plan to a 2010 Standardized plan, the offer and subsequent exchange shall comply with the following requirements:
i. A carrier 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 pre-funding inherent in the use of an issue age rate basis, for the benefit of the insured. The method proposed to be used by a carrier must be filed with the Commissioner.
ii. The rating class of the new policy or certificate shall be the class closest to the insured's class of the replaced coverage.
iii. A carrier may not apply new pre-existing 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 pre-existing condition limitations of no more than six months to any added benefits contained in the new 2010 Standardized policy or certificate that are not contained in the exchanged policy.
iv. The new policy or certificate shall be offered to all policyholders or certificateholders within a given plan, except where the offer or issue would be in violation of state or Federal law.