Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-66 - Washington medicare supplement insurance regulation › Section 284-66-063 - Benefit standards for policies or certificates issued or delivered after June 30, 1992 and before 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.
(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 may 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) 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.
(d) Each medicare supplement policy must 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 must offer certificate holders an
			 individual medicare supplement policy that (at the option of the certificate
			 holder) provides for continuation of the benefits contained in the group
			 policy, or 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 offer the
			 certificate holder the conversion opportunity described in (c)(iii) of this
			 subsection, or 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 issuer of the replacement policy must 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 any exclusion for preexisting conditions
			 that would have been covered under the group policy being replaced.
(e) Termination of a medicare
			 supplement policy or certificate must be without prejudice to any continuous
			 loss that began while the policy was in force, but the extension of benefits
			 beyond the period that 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.
(f) If a medicare supplement
			 policy or certificate 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 or certificate is deemed to
			 satisfy the guaranteed renewal requirements of this section.
(g)
(i) A
			 medicare supplement policy or certificate must provide that benefits and
			 premiums under the policy or certificate must be suspended at the request of
			 the policyholder or certificate holder for the period (not to exceed
			 twenty-four months) that 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 the assistance.
(ii) If the suspension occurs and if the
			 policyholder or certificate holder loses entitlement to medical assistance, the
			 policy or certificate must be automatically reinstituted effective as of the
			 date of termination of the entitlement if the policyholder or certificate
			 holder provides notice of loss of the entitlement 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 entitlement.
(iii) Each medicare supplement policy must
			 provide that benefits and premiums under the policy will 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 within ninety days after the date of the
			 loss).
(h) Reinstitution
			 of the coverages:
(i) May not provide for any
			 waiting period with respect to treatment of preexisting conditions;
(ii) Must provide for resumption of coverage
			 that is substantially equivalent to coverage in effect before the date of the
			 suspension. If the suspended medicare supplement policy or certificate provided
			 coverage for outpatient prescription drugs, reinstitution of the policy for
			 medicare Part D enrollees must be without coverage for outpatient prescription
			 drugs and must otherwise provide substantially equivalent coverage to the
			 coverage in effect before the date of suspension; and
(iii) 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.