Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-66 - Washington medicare supplement insurance regulation › Section 284-66-064 - Benefit standards for policies or certificates issued or delivered on or after June 1, 2010

Current through Register Vol. 24-14, July 15, 2024
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. Benefit
				standards applicable to medicare supplement policies or certificates issued
				before June 1, 2010, remain subject to the requirements of WAC
				284-66-060
				and
				284-66-063.
(1) General standards. The following
			 standards apply to medicare supplement policies and certificates and are in
			 addition to all other requirements of this regulation.
(a) A medicare supplement policy or
			 certificate shall not exclude or limit benefits for losses incurred more than
			 three 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 three
			 months before the effective date of coverage.
(b) A medicare supplement policy or
			 certificate must 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. Premiums
			 may be modified to correspond with such changes.
(c) No medicare supplement policy or
			 certificate may 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.
(d) Each medicare supplement policy shall be
			 guaranteed renewable and:
(i) The issuer may
			 not cancel or nonrenew the policy solely on the ground of health status of the
			 individual; and
(ii) The issuer may
			 not cancel or nonrenew the policy for any reason other than nonpayment of
			 premium or material misrepresentation.
(iii) If the medicare supplement policy is
			 terminated by the group policyholder and is not replaced as provided under
			 (d)(v) of this subsection, the issuer shall offer certificate holders an
			 individual medicare supplement policy which, at the option of the certificate
			 holder:
(A) Provides for continuation of the
			 benefits contained in the group policy; or
(B) Provides for benefits that otherwise meet
			 the requirements of this subsection.
(iv) If an individual is a certificate holder
			 in a group medicare supplement policy and the individual terminates membership
			 in the group, the issuer must:
(A) Offer the
			 certificate holder the conversion opportunity described in (d)(iii) of this
			 subsection; or
(B) At the option of
			 the group policyholder, offer the certificate holder continuation of coverage
			 under the group policy.
(v) If a group medicare supplement policy is
			 replaced by another group medicare supplement policy purchased by the same
			 policyholder, the issue of the replacement policy must offer coverage to all
			 persons covered under the old group policy on its date of
			 termination.
(vi) Termination of a
			 medicare supplement policy or certificate must 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)
(A) A
			 medicare supplement policy or certificate must provide that benefits and
			 premiums under the policy or certificate are suspended at the request of the
			 policyholder or certificate holder for the period not to exceed twenty-four
			 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 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 within ninety 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 must provide that benefits and premiums under
			 the policy must 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 must be
			 automatically reinstituted effective as of the date of loss of coverage if the
			 policyholder provides notice of loss of coverage within ninety 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.
(viii) Reinstitution of coverages
			 as described in this section:
(A) Must not
			 provide for any waiting period with respect to treatment of preexisting
			 conditions;
(B) Must provide for
			 resumption of coverage that is substantially equivalent to coverage in effect
			 before the date of suspension; and
(C) Must 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.