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 - Benefit standards for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates issued or delivered on or after July 1, 1992 and Prior to 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 July 1, 1992 and 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.
(b)
General standards.
The following standards apply to Medicare
				  supplement policies and certificates and are in addition to all other
				  requirements of this Part.
(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 cast 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
				  percentage 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 and
(A) The issuer shall not cancel or nonrenew
				  the policy solely on the ground of health status of the individual;
				  and
(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 (b)(5)(E) of this section, 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 such benefits as otherwise
				  meets 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 (b)(5)(C) of this
				  section, 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 succeeding issuer 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.
(F) 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.
(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
				  such policy or certificate within ninety (90) days after the date the
				  individual becomes entitled to such assistance.
(B) If such suspension occurs and if the
				  policyholder or certificateholder loses entitlement to such medical assistance,
				  such policy or certificate shall be automatically reinstituted effective as of
				  the date of termination of such entitlement if the policyholder or
				  certificateholder provides notice of loss of such entitlement within ninety
				  (90) days after the date of such loss and pays the premium attributable to the
				  period.
(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 certificate holder 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 such
				  coverages:
(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 such
				  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) 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.
(8) If an issuer 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 as described in O.A.C. 365:10-5-127 to a 2010 Standardized plan as
				  described in O.A.C.
				  365:10-5-127.1,
				  the offer and subsequent exchange shall comply with the following requirements:
(A) 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 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 an issuer must be filed with the commissioner according
				  to the state's rate filing procedure.
(B) The rating class of the new policy or
				  certificate shall be the class closest to the insured's class of the replaced
				  coverage.
(C) An issuer 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 (6) months to any added benefits
				  contained in the new 2010 Standardized policy or certificate not contained in
				  the exchanged policy.
(D) 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.