West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-24 - Medicare Supplement Insurance › Section 114-24-6A - 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 Register Vol. XLI, No. 28, July 12, 2024
6A.1. 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 sections 6 and 7 of this rule.
6A.2. General Standards. The following standards
				apply to Medicare supplement policies and certificates and are in addition to all
				other requirements of this rule.
6A.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 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.
6A.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.
6A.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, co-payment, 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.
6A.2.d. 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.
6A.2.e. Each Medicare supplement policy shall be
				guaranteed renewable.
6A.2.e.1. The issuer shall
				not cancel or non-renew the policy solely on the ground of health status of the
				individual.
6A.2.e.2. The issuer shall
				not cancel or non-renew the policy for any reason other than nonpayment of premium
				or material misrepresentation.
6A.2.e.3.
				If the Medicare supplement policy is terminated by the group policyholder and is not
				replaced as provided under paragraph 5 of this subdivision, the issuer shall offer
				certificate holders an individual Medicare supplement policy which (at the option of
				the certificate holder):
6A.2.e.3.A. Provides for
				continuation of the benefits contained in the group policy; or
6A.2.e.3.B. Provides for benefits that otherwise
				meet the requirements of this subsection.
6A.2.e.4. If an individual is a certificate holder
				in a group Medicare supplement policy and the individual terminates membership in
				the group, the issuer shall:
6A.2.e.4.A. Offer the
				certificate holder the conversion opportunity described in paragraph 3 of this
				subdivision; or
6A.2.e.4.B. At the
				option of the group policyholder, offer the certificate holder continuation of
				coverage under the group policy.
6A.2.e.5. 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.
6A.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 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.
6A.2.g.
6A.2.g.1. 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 policy holder 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.
6A.2.g.2. 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.
6A.2.g.3. 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.
6A.2.g.4. Reinstitution of coverages as described
				in paragraphs 2 and 3 of this subdivision:
6A.2.g.4.A. Shall not provide for any waiting
				period with respect to treatment of preexisting conditions;
6A.2.g.4.B. Shall provide for resumption of
				coverage that is substantially equivalent to coverage in effect before the date of
				suspension; and
6A.2.g.4.C. 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.