West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-24 - Medicare Supplement Insurance › Section 114-24-5 - Minimum Benefit Standards for Pre-Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery Prior to August 5, 1991

Current through Register Vol. XLI, No. 28, July 12, 2024
5.1. No policy or
				certificate may be advertised, solicited or issued for delivery in this state as a
				Medicare supplement policy or certificate unless it meets or exceeds the minimum
				standards set forth in this section. These are minimum standards and do not preclude
				the inclusion of other provisions or benefits which are not inconsistent with these
				standards.
5.2. General Standards. --
				The following standards apply to Medicare supplement policies and certificates and
				are in addition to all other requirements of this rule.
5.2.a. 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 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 (6) months before the effective date of
				coverage.
5.2.b. A Medicare supplement
				policy or certificate shall not indemnify against losses resulting from sickness on
				a different basis than losses resulting from accidents.
5.2.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. Premium modifications to
				correspond to these changes are permissible subject to prior approval of the
				Commissioner. Any proposed premium modifications shall be filed with the
				Commissioner in compliance with procedures applicable to accident and sickness
				filings generally and with other applicable sections of this rule.
5.2.d. A "noncancellable," "guaranteed renewable,"
				or "noncancellable and guaranteed renewable" Medicare supplement policy shall not:
5.2.d.1. 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
5.2.d.2. Be canceled or nonrenewed by the issuer
				solely on the grounds of deterioration of health.
5.2.e. Except as authorized by the Commissioner,
				an issuer shall neither cancel nor nonrenew a Medicare supplement policy or
				certificate for any reason other than nonpayment of premium or material
				misrepresentation.
5.2.e.1. If a group Medicare
				supplement insurance policy is terminated by the group policyholder and not replaced
				as provided in paragraph 3 of this subdivision, the issuer shall offer certificate
				holders an individual Medicare supplement policy. The issuer shall offer the
				certificate holder at least the following choices:
5.2.e.1.A. An individual Medicare supplement
				policy currently offered by the issuer having comparable benefits to those contained
				in the terminated group Medicare supplement policy; and
5.2.e.1.B. An individual Medicare supplement
				policy which provides only the benefits as are required to meet the minimum
				standards as defined in subsection 6A.3 of this rule.
5.2.e.2. If membership in a group is terminated,
				the issuer shall:
5.2.e.2.A. Offer the certificate
				holder the conversion opportunities described in paragraph 1 of this subdivision;
				or
5.2.e.2.B. At the option of the group
				policyholder, offer the certificate holder continuation of coverage under the group
				policy.
5.2.e.3. 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.
5.2.f. 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 predicated
				upon the continuous total disability of the insured, limited to the duration of the
				policy benefit period, if any, or to payment of the maximum benefits. Receipt of
				Medicare Part D benefits will not be considered in determining a continuous
				loss.
5.2.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 subsection.