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-20-30-7.9 - Benefit Standards for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery with an Effective Date for Coverage on or After 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 with an effective date for
				  coverage 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
				  standards. No issuer may offer any 1990 Standardized Medicare supplement
				  benefit plan for sale on or after June 1, 2010. Benefit standards applicable to
				  Medicare supplement policies and certificates issued with an effective date for
				  coverage prior to June 1, 2010 remain subject to the requirements of this Part
				  governing such policies and certificates.
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 §
												7.9(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 §
													7.9(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.
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.
				  Medicare Supplement Policy Suspension Guidelines
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.
				  42 U.S.C. §
													1395 et seq .
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 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 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
				  §
												7.9(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; 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.