Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter K - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 89.776a - Benefit standards for policies or certificates issued or delivered on or after June 1, 2010

Current through Register Vol. 54, No. 28, July 13, 2024
The following standards apply to 2010 Standardized Medicare
					 supplement benefit plans. An issuer may not offer any 1990 Standardized
					 Medicare supplement benefit plan for sale on or after June 1, 2010. A policy or
					 certificate may not be advertised, solicited, delivered or issued for delivery
					 in this Commonwealth as a Medicare supplement policy or certificate unless it
					 complies with these benefit standards.
(1)
General standards
. The
				  following standards apply to Medicare supplement policies and certificates and
				  are in addition to all other requirements of this regulation.
(i)
Exclusions or
				  limitations
. A Medicare supplement policy or certificate may not
				  exclude or limit benefits for losses incurred more than 6 months after 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 6 months before the
				  effective date of coverage.
(ii)
Indemnification of sickness and accidents
. A Medicare
				  supplement policy or certificate may not indemnify against losses resulting
				  from sickness on a different basis than losses resulting from
				  accidents.
(iii)
Cost
				  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, co-payment or coinsurance amounts. Premiums
				  may be modified to correspond with these changes.
(iv)
Termination of coverage
. A Medicare supplement policy or certificate may not 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.
(v)
Cancellation
				  or nonrenewal of policy
. Each Medicare supplement policy is guaranteed
				  renewable.
(A) The issuer may not cancel or
				  nonrenew the policy solely on the ground of health status of the
				  individual.
(B) The issuer may 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 clause (E), the issuer shall offer
				  certificateholders an individual Medicare supplement policy which, at the
				  option of the certificateholder, does one of the following:
(I) Provides for continuation of the benefits
				  contained in the group policy.
(II)
				  Provides for benefits that otherwise meet the requirements of this
				  section.
(D) If an
				  individual is a certificateholder in a group Medicare supplement policy and the
				  individual terminates membership in the group, the issuer shall do one of the
				  following:
(I) Offer the certificate holder
				  the conversion opportunity described in clause (C).
(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 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 may not result in an
				  exclusion for preexisting conditions that would have been covered under the
				  group policy being replaced.
(vi)
Extension of benefits
.
				  Termination of a Medicare supplement policy or certificate is without prejudice
				  to any continuous loss which began 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.
(vii)
Suspension by
				  policyholder
.
(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 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
				  (42 U.S.C.A. §§
													1396-1396u), but only if the
				  policyholder or certificateholder notifies the issuer of the policy or
				  certificate within 90 days after the date the individual becomes entitled to
				  this assistance.
(B) If a
				  suspension occurs and if the policyholder or certificateholder 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
				  certificateholder provides notice of loss of entitlement within 90 days after
				  the date of loss and pays the premium attributable to the period, effective as
				  of the date of the termination of entitlement.
(C) Each Medicare supplement policy shall
				  provide that benefits and premiums under the policy shall be suspended at the
				  request of the policyholder if the policyholder is entitled to benefits under
				  section 226(b) of the Social Security Act (42 U.S.C.A. §
													426(b)) and is covered under
				  a group health plan (as defined in section 1862 (b)(1)(A)(v) of the Social
				  Security Act (42 U.S.C.A.
				  §
													1395y(b)(1)(A)(v)).
				  If suspension occurs and if the policyholder or certificateholder 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 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 clauses (B) and (C):
(I) May 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 suspension.
(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 if the coverage had not been
				  suspended.