Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 52 - INSURANCE POLICIES › Section 836-052-0134 - Minimum Benefit Standards for Policies or Certificates Issued for Delivery Prior to July 1, 1992

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A
			 policy or certificate may not be advertised, solicited or issued for delivery
			 in this state as a Medicare supplement policy or certificate unless it meets or
			 exceeds the standards described in this rule. The standards described in this
			 rule are minimum standards and do not preclude the inclusion of other
			 provisions or benefits that are not inconsistent with the standards.
(2) The following standards apply to Medicare
			 supplement policies and certificates and are in addition to all other
			 requirements of OAR 836-052-0103  to 836-052-0194:
(a) A Medicare supplement policy or
			 certificate shall not exclude or limit benefits for losses insured more than
			 six months from the effective date of coverage because it involved a
			 preexisting condition. The policy or certificate shall 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
			 months before the effective date of coverage;
(b) A Medicare supplement policy or
			 certificate shall not indemnify against losses resulting from sickness on a
			 different basis than losses resulting from accidents;
(c) 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, copayment or coinsurance amounts and
			 copayment percentage factors. Premiums may be modified to correspond with such
			 changes. An insurer must justify any premium modification actuarially and must
			 obtain approval from the Director before implementing the
			 modification;
(d) A
			 "noncancelable," "guaranteed renewable" or "noncancelable and guaranteed
			 renewable" Medicare supplement policy shall not:
(A) 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; or
(B) Be canceled or nonrenewed by the issuer
			 on the grounds of deterioration of health.
(e)
(A)
			 Except as authorized by the Director, an issuer shall neither cancel nor
			 nonrenew a Medicare supplement policy or certificate for any reason other than
			 nonpayment of premium or a material misrepresentation;
(B) If a group Medicare supplement insurance
			 policy is terminated by the group policyholder and not replaced as provided in
			 paragraph (D) of this subsection, the issuer shall offer certificate holders an
			 individual Medicare supplement policy. The issuer shall offer the certificate
			 holder at least the following choices:
(i) An
			 individual Medicare supplement policy currently offered by the issuer having
			 comparable benefits to those contained in the terminated group Medicare
			 supplement policy; and
(ii) An
			 individual Medicare supplement policy that provides only such benefits as are
			 required to meet the minimum standards as defined in OAR
			 836-052-0133(3).
(C) If
			 membership in a group is terminated, the issuer shall:
(i) Offer the certificate holder the
			 conversion opportunities described in paragraph (B) of this subsection;
			 or
(ii) At the option of the group
			 policyholder, offer the certificate holder continuation of coverage under the
			 group policy.
(D) 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 group policy
			 shall not result in any exclusion for preexisting conditions that would have
			 been covered under the group policy being replaced;
(E) This subsection does not prohibit rate
			 increases otherwise authorized by law.
(f) Termination of a Medicare supplement
			 policy or certificate shall be without prejudice to any continuous loss that
			 commenced while the policy was in force, but the extension of benefits beyond
			 the period during which the policy was in force may be predicated 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.
(g) 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 section.