West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-24 - Medicare Supplement Insurance › Section 114-24-6 - Benefit Standards for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or After August 5, 1991 and with an Effective Date for Coverage Prior to June 1, 2010

Current through Register Vol. XLI, No. 28, July 12, 2024
6.1. The standards set forth in this section are
				applicable to all Medicare supplement policies or certificates delivered or issued
				for delivery in this state on or after August 5, 1991 and with an effective date of
				coverage prior to 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.
6.2. General Standards. -- The following standards
				apply to Medicare supplement policies and certificates and are in addition to all
				other requirements of this rule.
6.2.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.
6.2.b. A Medicare supplement policy or certificate
				shall not indemnify against losses resulting from sickness on a different basis than
				losses resulting from accidents.
6.2.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.
6.2.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.
6.2.e. Each Medicare supplement policy shall be
				guaranteed renewable.
6.2.e.1. The issuer shall not
				cancel or nonrenew the policy solely on the ground of health status of the
				individual; and
6.2.e.2. The issuer
				shall not cancel or nonrenew the policy for any reason other than nonpayment of
				premium or material misrepresentation.
6.2.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):
6.2.e.3.A. Provides for continuation of the
				benefits contained in the group policy, or
6.2.e.3.B. Provides for benefits that otherwise
				meet the requirements of this subsection.
6.2.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:
6.2.e.4.A. Offer the
				certificate holder the conversion opportunity described in paragraph 3 of this
				subdivision; or
6.2.e.4.B. At the option
				of the group policyholder, offer the certificate holder continuation of coverage
				under the group policy.
6.2.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.
6.2.e.6. 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 subdivision.
6.2.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 to payment of the maximum benefits. Receipt of Medicare Part D benefits will
				not be considered in determining a continuous loss.
6.2.g.
6.2.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 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.
6.2.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.
6.2.g.3. Each Medicare
				supplement policy shall provide that benefits and premiums under the policy shall be
				suspended (for the period 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 loss and pays the premium attributable to the period,
				effective as of the date of termination of entitlement.
6.2.g.4. Reinstitution of coverages as described
				in paragraphs 2 and 3 of this subdivision:
6.2.g.4.A. Shall not provide for any waiting
				period with respect to treatment of preexisting conditions;
6.2.g.4.B. 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
6.2.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.
6.2.h.
				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 7 of this
				rule) to a 2010 Standardized plan (as described in section 7A of this rule), the
				offer and subsequent exchange shall comply with the following requirements:
6.2.h.1. 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 the 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 in a manner prescribed by the
				Commissioner.
6.2.h.2. The rating class
				of the new policy or certificate shall be the class closest to the insured's class
				of the replaced coverage.
6.2.h.3. 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 six (6) months to any added
				benefits contained in the new 2010 Standardized policy or certificate not contained
				in the exchanged policy.
6.2.h.4. 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.