Wyoming Administrative Code › Agency 044 - Insurance Dept › Sub-Agency 0002 - General Agency, Board or Commission Rules › Chapter 35 - MEDICARE SUPPLEMENT INSURANCE › Section 35-8 - Benefit Standards for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or After July 30, 1992 and with an Effective Date for Coverage Prior to June 1, 2010

Current through July 13, 2024
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, 2010No 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.
(a) General Standards. The following
				standards apply to Medicare supplement policies and certificates and are in
				addition to all other requirements of this regulation.
(i) A Medicare supplement policy or
				certificate shall not exclude or limit benefits for losses incurred more than
				ninety (90) days 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
				ninety (90) days before the effective date of coverage.
(ii) A Medicare supplement policy or
				certificate shall not indemnify against losses resulting from sickness on a
				different basis than losses resulting from accidents.
(iii) 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.
(iv) 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.
(v) 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
				Section 8(a)(v)(E), the issuer shall offer certificate holders an individual
				Medicare supplement policy which (at the option of the certificate holder):
(I) Provides for continuation of the benefits
				contained in the group policy, or
(II) 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:
(I) Offer the
				certificate holder the conversion opportunity described in Section 8(a)(v)(C),
				or
(II) 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, the modified policy shall be deemed to satisfy the guaranteed renewal
				requirements of this paragraph.
(vi) 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.
(vii) Suspension.
(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 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.
(D) Reinstitution of coverages.
(I) Shall 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. 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
(III) 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.
(viii) 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 Section
				9 of this regulation) to a [2010
				Standardized plan] (as described in Section 9.1 of this regulation), 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 according
				to Section
				15(c).
(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 ninety (90) days 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.