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 365:10-5-128.2 - Standard Medicare supplement benefit plans 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) 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 plan standards. Benefit plan 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) An issuer shall make available to each
				  prospective policyholder and certificateholder a policy form or certificate
				  form containing only the basic (core) benefits, as defined in O.A.C.
				  365:10-5-127.1. If an issuer
				  makes available any of the additional benefits described in O.A.C.
				  365:10-5-127.1(d),
				  or offers standardized benefit Plans K or L (as described in O.A.C
				  365:10-5-128.3(f)(8) and
				  (9) ), then the issuer shall make available
				  to each prospective policyholder and certificateholder, in addition to a policy
				  form or certificate form with only the basic (core) benefits as described
				  above, a policy form or certificate form containing either standardized benefit
				  Plan C (as described in O.A.C. 365:10-5-128.2(f)(3) ) or standardized benefit
				  Plan F (as described in O.A.C. 365:10-5-128.2(f)(5) ).
(c) 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 O.A.C.
				  365:10-5-128.2(g) and in O.A.C.
				  365:10-5-128.3.
(d) Benefit plans shall be uniform in
				  structure, language, designation and format to the standard benefit plans
				  listed in this Subsection and conform to the definitions in O.A.C.
				  365:10-5-123. Each benefit shall
				  be structured in accordance with the format provided in O.A.C.
				  365:10-5-127.1(c) and
				  (d); or, in the case of plans K or L, in
				  O.A.C. 365:10-5-128.2(f)(8) or (9) of this regulation and list the benefits in
				  the order shown. For purposes of this Section, "structure, language, and
				  format" means style, arrangement and overall content of a benefit.
(e) In addition to the benefit plan
				  designations required in Subsection (d) of this section, an issuer may use
				  other designations to the extent permitted by law.
(f) Make-up of 2010 Standardized Benefit
				  Plans:
(1) Standardized Medicare supplement
				  benefit Plan A shall include only the following: The basic (core) benefits as
				  defined in O.A.C.
				  365:10-5-127.1(c).
(2) Standardized Medicare supplement benefit
				  Plan B shall include only the following: The basic (core) benefit as defined in
				  Section of this regulation, plus one hundred percent (100%) of the Medicare
				  Part A deductible as defined in
				  365:10-5-127.1(d)(1).
(3) Standardized Medicare supplement benefit
				  Plan C shall include only the following: The basic (core) benefit as defined in
				  O.A.C. 365:10-5-127.1(c),
				  plus one hundred percent (100%) of the Medicare Part A deductible, skilled
				  nursing facility care, one hundred percent (100%) of the Medicare Part B
				  deductible, and medically necessary emergency care in a foreign country as
				  defined in O.A.C.
				  365:10-5-127.1(d)(1), (3), (4), and
				  (6), respectively.
(4) Standardized Medicare supplement benefit
				  Plan D shall include only the following: The basic (core) benefit (as defined
				  in O.A.C.
				  365:10-5-127.1(c),
				  plus one hundred percent (100%) of the Medicare Part A deductible, skilled
				  nursing facility care, and medically necessary emergency care in an foreign
				  country as defined in O.A.C.
				  365:10-5-127.1(d)
				  (1), (3), and (6), respectively.
(5) Standardized Medicare supplement
				  [regular] Plan F shall include only the following: The basic (core) benefit as
				  defined in O.A.C.
				  365:10-5-127.1(c),
				  plus one hundred percent (100%) of the Medicare Part A deductible, the skilled
				  nursing facility care, one hundred percent (100%) of the Medicare Part B
				  deductible, one hundred percent (100%) of the Medicare Part B excess charges,
				  and medically necessary emergency care in a foreign country as defined in
				  O.A.C. 365:10-5-127.1(d)
				  (1), (3), (4), (5), and (6).
(6)
				  Standardized Medicare supplement Plan F With High Deductible shall include only
				  the following: one hundred percent (100%) of covered expenses following the
				  payment of the annual deductible set forth in Subparagraph (b).
(A) The basic (core) benefit as defined in
				  365:10-5-127.1(c),
				  plus one hundred percent (100%) of the Medicare Part A deductible, skilled
				  nursing facility care, one hundred percent (100%) of the Medicare Part B
				  deductible, one hundred percent (100%) of the Medicare Part B excess charges,
				  and medically necessary emergency care in a foreign country as defined in
				  365:10-5-127.1(d)
				  (1), (3), (4), (5), and (6).
(B)
				  The annual deductible in Plan F With High Deductible shall consist of
				  out-of-pocket expenses, other than premiums, for services covered by regular
				  Plan F, and shall be in addition to any other specific benefit deductibles. The
				  basis for the deductible shall be $1,500 and shall be adjusted annually from
				  1999 by the Secretary of the U.S. Department of Health and Human Services to
				  reflect the change in the Consumer Price Index for all urban consumers for the
				  twelve-month period ending with August of the preceding year, and rounded to
				  the nearest multiple of ten dollars ($10).
(7) Standardized Medicare supplement benefit
				  Plan G shall include only the following: The basic (core) benefit as defined in
				  365:10-5-127.1(c),
				  plus one hundred percent (100%) of the Medicare Part A deductible, skilled
				  nursing facility care, one hundred percent (100%) of the Medicare Part B excess
				  charges, and medically necessary emergency care in a foreign country as defined
				  in 365:10-5-127.1(d)
				  (1), (3), (5), and (6), respectively. Effective January 1, 2020, the
				  standardized benefit plans described in 128.4(b)(4) of this part (Redesignated
				  Plan G High Deductible) may be offered to any individual who was eligible for
				  Medicare prior to January 1, 2020.
(8) Standardized Medicare supplement Plan K
				  is mandated by The Medicare Prescription Drug, Improvement and Modernization
				  Act of 2003, and shall include only the following:
(A) Part A Hospital Coinsurance 61st through
				  90th days: Coverage of one hundred percent (100%) of the Part A hospital
				  coinsurance amount for each day used from the 61st through the 90th day in any
				  Medicare benefit period;
(B) Part A
				  Hospital Coinsurance, 91st through 150th days: Coverage of one hundred percent
				  (100%) of the Part A hospital coinsurance amount for each Medicare lifetime
				  inpatient reserve day used from the 91st through the 150th day in any Medicare
				  benefit period;
(C) Part A
				  Hospitalization After Lifetime Reserve Days are Exhausted: Upon exhaustion of
				  the Medicare hospital inpatient coverage, including the lifetime reserve days,
				  coverage of one hundred percent (100%) of the Medicare Part A eligible expenses
				  for hospitalization paid at the applicable prospective payment system (PPS)
				  rate, or other appropriate Medicare standard of payment, subject to a lifetime
				  maximum benefit of an additional 365 days. The provider shall accept the
				  issuer's payment as payment in full and may not bill the insured for any
				  balance;
(D) Medicare Part A
				  Deductible: Coverage for fifty percent (50%) of the Medicare Part A inpatient
				  hospital deductible amount per benefit period until the out-of-pocket
				  limitation is met as described in Subparagraph (x);
(E) Skilled Nursing Facility Care: Coverage
				  for fifty percent (50%) of the coinsurance amount for each day used 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 until the
				  out-of-pocket limitation is met as described in Subparagraph (x);
(F) Hospice Care: Coverage for fifty percent
				  (50%) of cost sharing for all Part A Medicare eligible expenses and respite
				  care until the out-of-pocket limitation is met as described in Subparagraph
				  (x);
(G) Blood: Coverage for fifty
				  percent (50%), under Medicare Part A or B, of the reasonable cost of the first
				  three (3) pints of blood (or equivalent quantities of packed red blood cells,
				  as defined under federal regulations) unless replaced in accordance with
				  federal regulations until the out-of-pocket limitation is met as described in
				  Subparagraph (x);
(H) Part B Cost
				  Sharing: Except for coverage provided in Subparagraph (ix), coverage for fifty
				  percent (50%) of the cost sharing otherwise applicable under Medicare Part B
				  after the policyholder pays the Part B deductible until the out-of-pocket
				  limitation is met as described in Subparagraph (x);
(I) Part B Preventive Services: Coverage of
				  one hundred percent (100%) of the cost sharing for Medicare Part B preventive
				  services after the policyholder pays the Part B deductible; and
(J) Cost Sharing After Out-of-Pocket Limits:
				  Coverage of one hundred percent (100%) of all cost sharing under Medicare Parts
				  A and B for the balance of the calendar year after the individual has reached
				  the out-of-pocket limitation on annual expenditures under Medicare Parts A and
				  B of $4000 in 2006, indexed each year by the appropriate inflation adjustment
				  specified by the Secretary of the U.S. Department of Health and Human
				  Services.
(9)
				  Standardized Medicare supplement Plan L is mandated by The Medicare
				  Prescription Drug, Improvement and Modernization Act of 2003, and shall include
				  only the following:
(A) The benefits
				  described in 365:10-5-128.2(f)(8)(A), (B), (C) and (I);
(B) The benefit described in
				  365:10-5-128.2(f)(8)(D), (E), (F), (G) and (H), but substituting seventy-five
				  percent (75%) for fifty percent (50%); and
(C) The benefit described in
				  365:10-5-128.2(f)(8)(J), but substituting $2000 for $4000.
(10) Standardized Medicare supplement Plan M
				  shall include only the following: The basic (core) benefit as defined in
				  365:10-5-127.1(c),
				  plus fifty percent (50%) of the Medicare Part A deductible, skilled nursing
				  facility care, and medically necessary emergency care in a foreign country as
				  defined in
				  365:10-5-127.1(d)(2), (3) and
				  (6).
(11) Standardized Medicare supplement Plan N
				  shall include only the following: The basic (core) benefit as defined in
				  365:10-5-127.1(c),
				  plus one hundred percent (100%) of the Medicare Part A deductible, skilled
				  nursing facility care, and medically necessary emergency care in a foreign
				  country as defined in
				  365:10-5-127.1(cd)(1), (3) and
				  (6), with copayments in the following
				  amounts:
(A) the lesser of twenty dollars
				  ($20) or the Medicare Part B coinsurance or copayment for each covered health
				  care provider office visit (including visits to medical specialists);
				  and
(B) the lesser of fifty dollars
				  ($50) or the Medicare Part B coinsurance or copayment for each covered
				  emergency room visit, however, this copayment shall be waived if the insured is
				  admitted to any hospital and the emergency visit is subsequently covered as a
				  Medicare Part A expense.