Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 7 - Medicare Supplement Insurance Minimum Standards › Section 230-RICR-20-30-7.8 - Benefit Standards for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued or Delivered on or After July 30, 1992 and with an Effective Date for Coverage Prior to June 1, 2010

Current through June 14, 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 July 30, 1992 and with an effective date for
				  coverage 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. 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. A Medicare supplement policy or
				  certificate shall not indemnify against losses resulting from sickness on a
				  different basis than losses resulting from accidents.
3. 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, co-payment, or coinsurance amounts.
				  Premiums may be modified to correspond with such changes.
4. 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. Each Medicare supplement policy shall be
				  guaranteed renewable.
a. The issuer shall not
				  cancel or non-renew the policy solely on the ground of health status of the
				  individual.
b. The issuer shall not
				  cancel or non-renew 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 §
												7.8(B)(5)(e)   of this Part, the issuer
				  shall offer certificate holders an individual Medicare supplement policy which
				  (at the option of the certificate holder)
(1)
				  Provides for continuation of the benefits contained in the group policy,
				  or
(2) Provides for benefits that
				  otherwise meet the requirements of this subsection.
d. If an individual is a certificate holder
				  in a group Medicare supplement policy and the individual terminates membership
				  in the group, the issuer shall
(1) Offer the
				  certificate holder the conversion opportunity described in §
													7.8(B)(5)(c)
				    of this Part, or;
(2) At the option
				  of the group policyholder, offer the certificate holder 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.
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 (MMA), the modified policy shall be deemed to
				  satisfy the guaranteed renewal requirements of this paragraph.
				  26 U.S.C. §
													139A.
6. 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 of Medicare
				  Supplement Policy
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
				  certificate holder for the period (not to exceed twenty-four (24) months) in
				  which the policyholder or certificate holder 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 certificate holder 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 certificate holder 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
				  certificate holder 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 §
												226(b)   of
				  the Social Security Act and is covered under a group health plan (as defined in
				  §
												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 and pays the premium
				  attributable to the period, effective as of the date of termination of
				  enrollment in the group health plan.
d. Reinstitution of coverages as described in
				  §
												7.8(B)(7)(b) and (c)   of this Part:
(1)
				  Shall not provide for any waiting period with respect to treatment of
				  preexisting conditions;
(2) Shall
				  provide for resumption of coverage that is substantially equivalent to coverage
				  in effect before the date of 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
(3) Shall provide for
				  classification of premiums on terms at least as favorable to the policyholder
				  or certificate holder as the premium classification terms that would have
				  applied to the policyholder or certificate holder had the coverage not been
				  suspended.
8.
				  If an issuer makes a written offer to the Medicare Supplement policyholders or
				  certificate holders of one or more of its plans, to exchange during a specified
				  period from his or her 1990 Standardized plan (as described in §
											7.10   of
				  this Part) to a 2010 Standardized plan (as described in §
											7.11   of this
				  Part), 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.
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 certificate holders within a given plan, except
				  where the offer or issue would be in violation of state or federal
				  law.