HB-5235, As Passed Senate, December 17, 2009

 

 

 

 

 

 

 

 

 

 

 

 

SENATE SUBSTITUTE FOR

 

HOUSE BILL NO. 5235

 

 

 

 

 

 

 

 

 

 

      A bill to amend 1956 PA 218, entitled

 

"The insurance code of 1956,"

 

by amending sections 3801, 3803, 3807, 3808, 3809, 3811, 3815,

 

3819, 3831, and 3839 (MCL 500.3801, 500.3803, 500.3807, 500.3808,

 

500.3809, 500.3811, 500.3815, 500.3819, 500.3831, and 500.3839),

 

sections 3801, 3807, 3809, 3811, 3815, 3819, 3831, and 3839 as

 

amended by 2006 PA 462 and sections 3803 and 3808 as added by

 

1992 PA 84, and by adding sections 3807a, 3809a, 3811a, and

 

3819a.

 

THE PEOPLE OF THE STATE OF MICHIGAN ENACT:

 

 1        Sec. 3801. As used in this chapter:

 

 2        (a) "Applicant" means:

 

 3        (i) For an individual medicare supplement policy, the person

 

 4  who seeks to contract for benefits.

 

 1        (ii) For a group medicare supplement policy or certificate,

 

 2  the proposed certificate holder.

 

 3        (b) "Bankruptcy" means when a medicare advantage

 

 4  organization that is not an insurer has filed, or has had filed

 

 5  against it, a petition for declaration of bankruptcy and has

 

 6  ceased doing business in this state.

 

 7        (c) "Certificate" means any certificate delivered or issued

 

 8  for delivery in this state under a group medicare supplement

 

 9  policy.

 

10        (d) "Certificate form" means the form on which the

 

11  certificate is delivered or issued for delivery by the insurer.

 

12        (e) "Continuous period of creditable coverage" means the

 

13  period during which an individual was covered by creditable

 

14  coverage, if during the period of the coverage the individual had

 

15  no breaks in coverage greater than 63 days.

 

16        (f) "Creditable coverage" means coverage of an individual

 

17  provided under any of the following:

 

18        (i) A group health plan.

 

19        (ii) Health insurance coverage.

 

20        (iii) Part A or part B of medicare.

 

21        (iv) Medicaid other than coverage consisting solely of

 

22  benefits under section 1928 of medicaid, 42 USC 1396s.

 

23        (v) Chapter 55 of title 10 of the United States Code, 10 USC

 

24  1071 to 1110.

 

25        (vi) A medical care program of the Indian health service or

 

26  of a tribal organization.

 

27        (vii) A state health benefits risk pool.

 

 1        (viii) A health plan offered under chapter 89 of title 5 of

 

 2  the United States Code, 5 USC 8901 to 8914.

 

 3        (ix) A public health plan as defined in federal regulation.

 

 4        (x) Health care under section 5(e) of title I of the peace

 

 5  corps act, 22 USC 2504.

 

 6        (g) "Direct response solicitation" means solicitation in

 

 7  which an insurer representative does not contact the applicant in

 

 8  person and explain the coverage available, such as, but not

 

 9  limited to, solicitation through direct mail or through

 

10  advertisements in periodicals and other media.

 

11        (h) "Employee welfare benefit plan" means a plan, fund, or

 

12  program of employee benefits as defined in section 3 of subtitle

 

13  A of title I of the employee retirement income security act of

 

14  1974, 29 USC 1002.

 

15        (i) "Insolvency" means when an insurer licensed to transact

 

16  the business of insurance in this state has had a final order of

 

17  liquidation entered against it with a finding of insolvency by a

 

18  court of competent jurisdiction in the insurer's state of

 

19  domicile.

 

20        (j) "Insurer" includes any entity, including a health care

 

21  corporation operating pursuant to the nonprofit health care

 

22  corporation reform act, 1980 PA 350, MCL 550.1101 to 550.1704,

 

23  delivering or issuing for delivery in this state medicare

 

24  supplement policies.

 

25        (k) "Medicaid" means title XIX of the social security act,

 

26  42 USC 1396 to 1396v.

 

27        (l) "Medicare" means title XVIII of the social security act,

 

 1  42 USC 1395 to 1395ggg 1395hhh.

 

 2        (m) "Medicare advantage" means a plan of coverage for health

 

 3  benefits under medicare part C as defined in section 12-2859 of

 

 4  part C of medicare, 42 USC 1395w-28, and includes any of the

 

 5  following:

 

 6        (i) Coordinated care plans that provide health care services,

 

 7  including, but not limited to, health maintenance organization

 

 8  plans with or without a point-of-service option, plans offered by

 

 9  provider-sponsored organizations, and preferred provider

 

10  organization plans.

 

11        (ii) Medical savings account plans coupled with a

 

12  contribution into a medicare advantage medical savings account.

 

13        (iii) Medicare advantage private fee-for-service plans.

 

14        (n) "Medicare supplement buyer's guide" means the document

 

15  entitled, "guide to health insurance for people with medicare",

 

16  developed by the national association of insurance commissioners

 

17  and the United States department of health and human services or

 

18  a substantially similar document as approved by the commissioner.

 

19        (o) "Medicare supplement policy" means an individual,

 

20  nongroup, or group policy or certificate that is advertised,

 

21  marketed, or designed primarily as a supplement to reimbursements

 

22  under medicare for the hospital, medical, or surgical expenses of

 

23  persons eligible for medicare and medicare select policies and

 

24  certificates under section 3817. Medicare supplement policy does

 

25  not include a policy, certificate, or contract of 1 or more

 

26  employers or labor organizations, or of the trustees of a fund

 

27  established by 1 or more employers or labor organizations, or

 

 1  both, for employees or former employees, or both, or for members

 

 2  or former members, or both, of the labor organizations. Medicare

 

 3  supplement policy does not include medicare advantage plans

 

 4  established under medicare part C, outpatient prescription drug

 

 5  plans established under medicare part D, or any health care

 

 6  prepayment plan that provides benefits pursuant to an agreement

 

 7  under section 1833(a)(1)(A) of the social security act.

 

 8        (p) "PACE" means a program of all-inclusive care for the

 

 9  elderly as described in the social security act.

 

10        (q) "Prestandardized medicare supplement benefit plan",

 

11  "prestandardized benefit plan", or "prestandardized plan" means a

 

12  group or individual policy of medicare supplement insurance

 

13  issued prior to June 2, 1992.

 

14        (r) "1990 standardized medicare supplement benefit plan",

 

15  "1990 standardized benefit plan", or "1990 plan" means a group or

 

16  individual policy of medicare supplement insurance issued on or

 

17  after June 2, 1992 with an effective date for coverage prior to

 

18  June 1, 2010 and includes medicare supplement insurance policies

 

19  and certificates renewed on or after that date which are not

 

20  replaced by the issuer at the request of the insured.

 

21        (s) "2010 standardized medicare supplement benefit plan",

 

22  "2010 standardized benefit plan", or "2010 plan" means a group or

 

23  individual policy of medicare supplement insurance with an

 

24  effective date for coverage on or after June 1, 2010.

 

25        (t) (q) "Policy form" means the form on which the policy or

 

26  certificate is delivered or issued for delivery by the insurer.

 

27        (u) (r) "Secretary" means the secretary of the United States

 

 1  department of health and human services.

 

 2        (v) (s) "Social security act" means the social security act,

 

 3  42 USC 301 to 1397jj.

 

 4        Sec. 3803. (1) Except as provided in subsection subsections

 

 5  (2) and (3), this chapter applies to a medicare supplement policy

 

 6  delivered, issued for delivery, or renewed in this state. on or

 

 7  after the effective date of this chapter.

 

 8        (2) Sections 3807, 3809, 3811, and 3819(1) do not apply 3819

 

 9  apply to a medicare supplement policy delivered or issued before

 

10  the effective date of this chapter for delivery in this state on

 

11  or after June 2, 1992 with an effective date for coverage prior

 

12  to June 1, 2010.

 

13        (3) Sections 3807a, 3809a, 3811a, and 3819a apply to a

 

14  medicare supplement policy delivered or issued for delivery in

 

15  this state with an effective date for coverage on or after June

 

16  1, 2010.

 

17        Sec. 3807. (1) Every insurer issuing a medicare supplement

 

18  insurance policy in this state shall make available a medicare

 

19  supplement insurance policy that includes a basic core package of

 

20  benefits to each prospective insured. An insurer issuing a

 

21  medicare supplement insurance policy in this state may make

 

22  available to prospective insureds benefits pursuant to section

 

23  3809 that are in addition to, but not instead of, the basic core

 

24  package. The basic core package of benefits shall include all of

 

25  the following:

 

26        (a) Coverage of part A medicare eligible expenses for

 

27  hospitalization to the extent not covered by medicare from the

 

 1  61st sixty-first day through the 90th ninetieth day in any

 

 2  medicare benefit period.

 

 3        (b) Coverage of part A medicare eligible expenses incurred

 

 4  for hospitalization to the extent not covered by medicare for

 

 5  each medicare lifetime inpatient reserve day used.

 

 6        (c) Upon exhaustion of the medicare hospital inpatient

 

 7  coverage including the lifetime reserve days, coverage of 100% of

 

 8  the medicare part A eligible expenses for hospitalization paid at

 

 9  the applicable prospective payment system rate or other

 

10  appropriate medicare standard of payment, subject to a lifetime

 

11  maximum benefit of an additional 365 days. The provider shall

 

12  accept the insurer's payment as payment in full and may not bill

 

13  the insured for any balance.

 

14        (d) Coverage under medicare parts A and B for the reasonable

 

15  cost of the first 3 pints of blood or equivalent quantities of

 

16  packed red blood cells, as defined under federal regulations

 

17  unless replaced in accordance with federal regulations.

 

18        (e) Coverage for the coinsurance amount, or the copayment

 

19  amount paid for hospital outpatient department services under a

 

20  prospective payment system, of medicare eligible expenses under

 

21  part B regardless of hospital confinement, subject to the

 

22  medicare part B deductible.

 

23        (2) Standards for plans K and L are as follows:

 

24        (a) Standardized medicare supplement benefit plan K shall

 

25  consist of the following:

 

26        (i) Coverage of 100% of the part A hospital coinsurance

 

27  amount for each day used from the sixty-first day through the

 

 1  ninetieth day in any medicare benefit period.

 

 2        (ii) Coverage of 100% of the part A hospital coinsurance

 

 3  amount for each medicare lifetime inpatient reserve day used from

 

 4  the ninety-first day through the one hundred fiftieth day in any

 

 5  medicare benefit period.

 

 6        (iii) Upon exhaustion of the medicare hospital inpatient

 

 7  coverage, including the lifetime reserve days, coverage of 100%

 

 8  of the medicare part A eligible expenses for hospitalization paid

 

 9  at the applicable prospective payment system rate, or other

 

10  appropriate medicare standard of payment, subject to a lifetime

 

11  maximum benefit of an additional 365 days. The provider shall

 

12  accept the insurer's payment as payment in full and may not bill

 

13  the insured for any balance.

 

14        (iv) Medicare part A deductible: coverage for 50% of the

 

15  medicare part A inpatient hospital deductible amount per benefit

 

16  period until the out-of-pocket limitation is met as described in

 

17  subparagraph (x).

 

18        (v) Skilled nursing facility care: coverage for 50% of the

 

19  coinsurance amount for each day used from the twenty-first day

 

20  through the one hundredth day in a medicare benefit period for

 

21  posthospital skilled nursing facility care eligible under

 

22  medicare part A until the out-of-pocket limitation is met as

 

23  described in subparagraph (x).

 

24        (vi) Hospice care: coverage for 50% of cost sharing for all

 

25  part A medicare eligible expenses and respite care until the out-

 

26  of-pocket limitation is met as described in subparagraph (x).

 

27        (vii) Coverage for 50%, under medicare part A or B, of the

 

 1  reasonable cost of the first 3 pints of blood or equivalent

 

 2  quantities of packed red blood cells, as defined under federal

 

 3  regulations, unless replaced in accordance with federal

 

 4  regulations until the out-of-pocket limitation is met as

 

 5  described in subparagraph (x).

 

 6        (viii) Except for coverage provided in subparagraph (ix) below,

 

 7  coverage for 50% of the cost sharing otherwise applicable under

 

 8  medicare part B after the policyholder pays the part B deductible

 

 9  until the out-of-pocket limitation is met as described in

 

10  subparagraph (x).

 

11        (ix) Coverage of 100% of the cost sharing for medicare part B

 

12  preventive services after the policyholder pays the part B

 

13  deductible.

 

14        (x) Coverage of 100% of all cost sharing under medicare

 

15  parts A and B for the balance of the calendar year after the

 

16  individual has reached the out-of-pocket limitation on annual

 

17  expenditures under medicare parts A and B of $4,000.00 in 2006,

 

18  indexed each year by the appropriate inflation adjustment

 

19  specified by the secretary of the United States department of

 

20  health and human services.

 

21        (b) Standardized medicare supplement benefit plan L shall

 

22  consist of the following:

 

23        (i) The benefits described in subdivision (a)(i), (ii), (iii),

 

24  and (ix).

 

25        (ii) The benefit described in subdivision (a)(iv), (v), (vi),

 

26  (vii), and (viii), but substituting 75% for 50%.

 

27        (iii) The benefit described in subdivision (a)(x), but

 

 1  substituting $2,000.00 for $4,000.00.

 

 2        (3) This section applies to medicare supplement policies or

 

 3  certificates delivered or issued for delivery with an effective

 

 4  date for coverage prior to June 1, 2010.

 

 5        Sec. 3807a. (1) This section applies to all medicare

 

 6  supplement policies or certificates delivered or issued for

 

 7  delivery with an effective date for coverage on or after June 1,

 

 8  2010. A policy or certificate shall not be advertised, solicited,

 

 9  delivered, or issued for delivery in this state as a medicare

 

10  supplement policy or certificate unless it complies with these

 

11  benefit standards. An issuer shall not offer any 1990 plan for

 

12  sale on or after June 1, 2010. Benefit standards applicable to

 

13  medicare supplement policies and certificates issued before June

 

14  1, 2010 remain subject to the requirements of section 3807.

 

15        (2) Every insurer issuing a medicare supplement insurance

 

16  policy in this state shall make available a medicare supplement

 

17  insurance policy that includes a basic core package of benefits

 

18  to each prospective insured. An insurer issuing a medicare

 

19  supplement insurance policy in this state may make available to

 

20  prospective insureds benefits pursuant to section 3809a that are

 

21  in addition to, but not instead of, the basic core package. The

 

22  basic core package of benefits shall include all of the

 

23  following:

 

24        (a) Coverage of part A medicare eligible expenses for

 

25  hospitalization to the extent not covered by medicare from the

 

26  sixty-first day through the ninetieth day in any medicare benefit

 

27  period.

 

 1        (b) Coverage of part A medicare eligible expenses incurred

 

 2  for hospitalization to the extent not covered by medicare for

 

 3  each medicare lifetime inpatient reserve day used.

 

 4        (c) Upon exhaustion of the medicare hospital inpatient

 

 5  coverage including the lifetime reserve days, coverage of 100% of

 

 6  the medicare part A eligible expenses for hospitalization paid at

 

 7  the applicable prospective payment system rate or other

 

 8  appropriate medicare standard of payment, subject to a lifetime

 

 9  maximum benefit of an additional 365 days. The provider shall

 

10  accept the insurer's payment as payment in full and may not bill

 

11  the insured for any balance.

 

12        (d) Coverage under medicare parts A and B for the reasonable

 

13  cost of the first 3 pints of blood or equivalent quantities of

 

14  packed red blood cells, as defined under federal regulations

 

15  unless replaced in accordance with federal regulations.

 

16        (e) Coverage for the coinsurance amount, or the copayment

 

17  amount paid for hospital outpatient department services under a

 

18  prospective payment system, of medicare eligible expenses under

 

19  part B regardless of hospital confinement, subject to the

 

20  medicare part B deductible.

 

21        (f) Coverage of cost sharing for all part A medicare

 

22  eligible hospice care and respite care expenses.

 

23        Sec. 3808. Every insurer issuing a medicare supplement

 

24  insurance policy in this state shall make available a medicare

 

25  supplement insurance policy that includes the benefits provided

 

26  in section 3811(5)(c) or 3811a(6)(c), whichever is applicable.

 

27        Sec. 3809. (1) In addition to the basic core package of

 

 1  benefits required under section 3807, the following benefits may

 

 2  be included in a medicare supplement insurance policy and if

 

 3  included shall conform to section 3811(5)(b) to (j):

 

 4        (a) Medicare part A deductible: coverage for all of the

 

 5  medicare part A inpatient hospital deductible amount per benefit

 

 6  period.

 

 7        (b) Skilled nursing facility care: coverage for the actual

 

 8  billed charges up to the coinsurance amount from the 21st day

 

 9  through the 100th day in a medicare benefit period for

 

10  posthospital skilled nursing facility care eligible under

 

11  medicare part A.

 

12        (c) Medicare part B deductible: coverage for all of the

 

13  medicare part B deductible amount per calendar year regardless of

 

14  hospital confinement.

 

15        (d) Eighty percent of the medicare part B excess charges:

 

16  coverage for 80% of the difference between the actual medicare

 

17  part B charge as billed, not to exceed any charge limitation

 

18  established by medicare or state law, and the medicare-approved

 

19  part B charge.

 

20        (e) One hundred percent of the medicare part B excess

 

21  charges: coverage for all of the difference between the actual

 

22  medicare part B charge as billed, not to exceed any charge

 

23  limitation established by medicare or state law, and the

 

24  medicare-approved part B charge.

 

25        (f) Basic outpatient prescription drug benefit: coverage for

 

26  50% of outpatient prescription drug charges, after a $250.00

 

27  calendar year deductible, to a maximum of $1,250.00 in benefits

 

 1  received by the insured per calendar year, to the extent not

 

 2  covered by medicare. The outpatient prescription drug benefit may

 

 3  be included for sale or issuance in a medicare supplement policy

 

 4  until January 1, 2006.

 

 5        (g) Extended outpatient prescription drug benefit: coverage

 

 6  for 50% of outpatient prescription drug charges, after a $250.00

 

 7  calendar year deductible, to a maximum of $3,000.00 in benefits

 

 8  received by the insured per calendar year, to the extent not

 

 9  covered by medicare. The outpatient prescription drug benefit may

 

10  be included for sale or issuance in a medicare supplement policy

 

11  until January 1, 2006.

 

12        (h) Medically necessary emergency care in a foreign country:

 

13  coverage to the extent not covered by medicare for 80% of the

 

14  billed charges for medicare-eligible expenses for medically

 

15  necessary emergency hospital, physician, and medical care

 

16  received in a foreign country, which care would have been covered

 

17  by medicare if provided in the United States and which care began

 

18  during the first 60 consecutive days of each trip outside the

 

19  United States, subject to a calendar year deductible of $250.00,

 

20  and a lifetime maximum benefit of $50,000.00. For purposes of

 

21  this benefit, "emergency care" means care needed immediately

 

22  because of an injury or an illness of sudden and unexpected

 

23  onset.

 

24        (i) Preventive medical care benefit: Coverage for the

 

25  following preventive health services not covered by medicare:

 

26        (i) An annual clinical preventive medical history and

 

27  physical examination that may include tests and services from

 

 1  subparagraph (ii) and patient education to address preventive

 

 2  health care measures.

 

 3        (ii) Preventive screening tests or preventive services, the

 

 4  selection and frequency of which is determined to be medically

 

 5  appropriate by the attending physician.

 

 6        (j) At-home recovery benefit: coverage for services to

 

 7  provide short term, at-home assistance with activities of daily

 

 8  living for those recovering from an illness, injury, or surgery.

 

 9  At-home recovery services provided shall be primarily services

 

10  that assist in activities of daily living. The insured's

 

11  attending physician shall certify that the specific type and

 

12  frequency of at-home recovery services are necessary because of a

 

13  condition for which a home care plan of treatment was approved by

 

14  medicare. Coverage is excluded for home care visits paid for by

 

15  medicare or other government programs and care provided by family

 

16  members, unpaid volunteers, or providers who are not care

 

17  providers. Coverage is limited to:

 

18        (i) No more than the number of at-home recovery visits

 

19  certified as necessary by the insured's attending physician. The

 

20  total number of at-home recovery visits shall not exceed the

 

21  number of medicare approved home health care visits under a

 

22  medicare approved home care plan of treatment.

 

23        (ii) The actual charges for each visit up to a maximum

 

24  reimbursement of $40.00 per visit.

 

25        (iii) One thousand six hundred dollars per calendar year.

 

26        (iv) Seven visits in any 1 week.

 

27        (v) Care furnished on a visiting basis in the insured's

 

 1  home.

 

 2        (vi) Services provided by a care provider as defined in this

 

 3  section.

 

 4        (vii) At-home recovery visits while the insured is covered

 

 5  under the insurance policy and not otherwise excluded.

 

 6        (viii) At-home recovery visits received during the period the

 

 7  insured is receiving medicare approved home care services or no

 

 8  more than 8 weeks after the service date of the last medicare

 

 9  approved home health care visit.

 

10        (k) New or innovative benefits: an insurer may, with the

 

11  prior approval of the commissioner, offer policies or

 

12  certificates with new or innovative benefits in addition to the

 

13  benefits provided in a policy or certificate that otherwise

 

14  complies with the applicable standards. The new or innovative

 

15  benefits may include benefits that are appropriate to medicare

 

16  supplement insurance, new or innovative, not otherwise available,

 

17  cost-effective, and offered in a manner that is consistent with

 

18  the goal of simplification of medicare supplement policies. After

 

19  December 31, 2005, the innovative benefit shall not include an

 

20  outpatient prescription drug benefit.

 

21        (2) Reimbursement for the preventive screening tests and

 

22  services under subsection (1)(i)(ii) shall be for the actual

 

23  charges up to 100% of the medicare-approved amount for each test

 

24  or service, as if medicare were to cover the test or service as

 

25  identified in the American medical association current procedural

 

26  terminology codes, to a maximum of $120.00 annually under this

 

27  benefit. This benefit shall not include payment for any procedure

 

 1  covered by medicare.

 

 2        (3) As used in subsection (1)(j):

 

 3        (a) "Activities of daily living" include, but are not

 

 4  limited to, bathing, dressing, personal hygiene, transferring,

 

 5  eating, ambulating, assistance with drugs that are normally self-

 

 6  administered, and changing bandages or other dressings.

 

 7        (b) "Care provider" means a duly qualified or licensed home

 

 8  health aide/homemaker, personal care aide, or nurse provided

 

 9  through a licensed home health care agency or referred by a

 

10  licensed referral agency or licensed nurses registry.

 

11        (c) "Home" means any place used by the insured as a place of

 

12  residence, provided that it qualifies as a residence for home

 

13  health care services covered by medicare. A hospital or skilled

 

14  nursing facility shall not be considered the insured's home.

 

15        (d) "At-home recovery visit" means the period of a visit

 

16  required to provide at home recovery care, without limit on the

 

17  duration of the visit, except each consecutive 4 hours in a 24-

 

18  hour period of services provided by a care provider is 1 visit.

 

19        (4) This section applies to medicare supplement policies or

 

20  certificates delivered or issued for delivery on or after June 2,

 

21  1992 with an effective date for coverage prior to June 1, 2010.

 

22        Sec. 3809a. (1) This section applies to all medicare

 

23  supplement policies or certificates delivered or issued for

 

24  delivery with an effective date for coverage on or after June 1,

 

25  2010.

 

26        (2) In addition to the basic core package of benefits

 

27  required under section 3807a, the following benefits may be

 

 1  included in a medicare supplement insurance policy and if

 

 2  included shall conform to section 3811a(6)(b) to (j):

 

 3        (a) Medicare part A deductible: coverage for 100% of the

 

 4  medicare part A inpatient hospital deductible amount per benefit

 

 5  period.

 

 6        (b) Medicare part A deductible: coverage for 50% of the

 

 7  medicare part A inpatient hospital deductible amount per benefit

 

 8  period.

 

 9        (c) Skilled nursing facility care: coverage for the actual

 

10  billed charges up to the coinsurance amount from the twenty-first

 

11  day through the one hundredth day in a medicare benefit period

 

12  for posthospital skilled nursing facility care eligible under

 

13  medicare part A.

 

14        (d) Medicare part B deductible: coverage for 100% of the

 

15  medicare part B deductible amount per calendar year regardless of

 

16  hospital confinement.

 

17        (e) One hundred percent of the medicare part B excess

 

18  charges: coverage for all of the difference between the actual

 

19  medicare part B charge as billed, not to exceed any charge

 

20  limitation established by medicare or state law, and the

 

21  medicare-approved part B charge.

 

22        (f) Medically necessary emergency care in a foreign country:

 

23  coverage to the extent not covered by medicare for 80% of the

 

24  billed charges for medicare-eligible expenses for medically

 

25  necessary emergency hospital, physician, and medical care

 

26  received in a foreign country, which care would have been covered

 

27  by medicare if provided in the United States and which care began

 

 1  during the first 60 consecutive days of each trip outside the

 

 2  United States, subject to a calendar year deductible of $250.00,

 

 3  and a lifetime maximum benefit of $50,000.00. For purposes of

 

 4  this benefit, "emergency care" means care needed immediately

 

 5  because of an injury or an illness of sudden and unexpected

 

 6  onset.

 

 7        Sec. 3811. (1) An insurer shall make available to each

 

 8  prospective medicare supplement policyholder and certificate

 

 9  holder a policy form or certificate form containing only the

 

10  basic core benefits as provided in section 3807.

 

11        (2) Groups, packages, or combinations of medicare supplement

 

12  benefits other than those listed in this section shall not be

 

13  offered for sale in this state except as may be permitted in

 

14  section 3809(1)(k).

 

15        (3) Benefit plans shall contain the appropriate A through L

 

16  designations, shall be uniform in structure, language, and format

 

17  to the standard benefit plans in subsection (5), and shall

 

18  conform to the definitions in this chapter. Each benefit shall be

 

19  structured in accordance with sections 3807 and 3809 and list the

 

20  benefits in the order shown in subsection (5). For purposes of

 

21  this section, "structure, language, and format" means style,

 

22  arrangement, and overall content of a benefit.

 

23        (4) In addition to the benefit plan designations A through L

 

24  as provided under subsection (5), an insurer may use other

 

25  designations to the extent permitted by law.

 

26        (5) A medicare supplement insurance benefit plan shall

 

27  conform to 1 of the following:

 

 1        (a) A standardized medicare supplement benefit plan A shall

 

 2  be limited to the basic core benefits common to all benefit plans

 

 3  as defined in section 3807.

 

 4        (b) A standardized medicare supplement benefit plan B shall

 

 5  include only the following: the core benefits as defined in

 

 6  section 3807 and the medicare part A deductible as defined in

 

 7  section 3809(1)(a).

 

 8        (c) A standardized medicare supplement benefit plan C shall

 

 9  include only the following: the core benefits as defined in

 

10  section 3807, the medicare part A deductible, skilled nursing

 

11  facility care, medicare part B deductible, and medically

 

12  necessary emergency care in a foreign country as defined in

 

13  section 3809(1)(a), (b), (c), and (h).

 

14        (d) A standardized medicare supplement benefit plan D shall

 

15  include only the following: the core benefits as defined in

 

16  section 3807, the medicare part A deductible, skilled nursing

 

17  facility care, medically necessary emergency care in a foreign

 

18  country, and the at-home recovery benefit as defined in section

 

19  3809(1)(a), (b), (h), and (j).

 

20        (e) A standardized medicare supplement benefit plan E shall

 

21  include only the following: the core benefits as defined in

 

22  section 3807, the medicare part A deductible, skilled nursing

 

23  facility care, medically necessary emergency care in a foreign

 

24  country, and preventive medical care as defined in section

 

25  3809(1)(a), (b), (h), and (i).

 

26        (f) A standardized medicare supplement benefit plan F shall

 

27  include only the following: the core benefits as defined in

 

 1  section 3807, the medicare part A deductible, skilled nursing

 

 2  facility care, medicare part B deductible, 100% of the medicare

 

 3  part B excess charges, and medically necessary emergency care in

 

 4  a foreign country as defined in section 3809(1)(a), (b), (c),

 

 5  (e), and (h). A standardized medicare supplement plan F high

 

 6  deductible shall include only the following: 100% of covered

 

 7  expenses following the payment of the annual high deductible plan

 

 8  F deductible. The covered expenses include the core benefits as

 

 9  defined in section 3807, plus the medicare part A deductible,

 

10  skilled nursing facility care, the medicare part B deductible,

 

11  100% of the medicare part B excess charges, and medically

 

12  necessary emergency care in a foreign country as defined in

 

13  section 3809(1)(a), (b), (c), (e), and (h). The annual high

 

14  deductible plan F deductible shall consist of out-of-pocket

 

15  expenses, other than premiums, for services covered by the

 

16  medicare supplement plan F policy, and shall be in addition to

 

17  any other specific benefit deductibles. The annual high

 

18  deductible plan F deductible is $1,790.00 for calendar year 2006,

 

19  and the secretary shall adjust it annually thereafter to reflect

 

20  the change in the consumer price index for all urban consumers

 

21  for the 12-month period ending with August of the preceding year,

 

22  rounded to the nearest multiple of $10.00.

 

23        (g) A standardized medicare supplement benefit plan G shall

 

24  include only the following: the core benefits as defined in

 

25  section 3807, the medicare part A deductible, skilled nursing

 

26  facility care, 80% of the medicare part B excess charges,

 

27  medically necessary emergency care in a foreign country, and the

 

 1  at-home recovery benefit as defined in section 3809(1)(a), (b),

 

 2  (d), (h), and (j).

 

 3        (h) A standardized medicare supplement benefit plan H shall

 

 4  include only the following: the core benefits as defined in

 

 5  section 3807, the medicare part A deductible, skilled nursing

 

 6  facility care, basic outpatient prescription drug benefit, and

 

 7  medically necessary emergency care in a foreign country as

 

 8  defined in section 3809(1)(a), (b), (f), and (h). The outpatient

 

 9  drug benefit shall not be included in a medicare supplement

 

10  policy sold after December 31, 2005.

 

11        (i) A standardized medicare supplement benefit plan I shall

 

12  include only the following: the core benefits as defined in

 

13  section 3807, the medicare part A deductible, skilled nursing

 

14  facility care, 100% of the medicare part B excess charges, basic

 

15  outpatient prescription drug benefit, medically necessary

 

16  emergency care in a foreign country, and at-home recovery benefit

 

17  as defined in section 3809(1)(a), (b), (e), (f), (h), and (j).

 

18  The outpatient drug benefit shall not be included in a medicare

 

19  supplement policy sold after December 31, 2005.

 

20        (j) A standardized medicare supplement benefit plan J shall

 

21  include only the following: the core benefits as defined in

 

22  section 3807, the medicare part A deductible, skilled nursing

 

23  facility care, medicare part B deductible, 100% of the medicare

 

24  part B excess charges, extended outpatient prescription drug

 

25  benefit, medically necessary emergency care in a foreign country,

 

26  preventive medical care, and at-home recovery benefit as defined

 

27  in section 3809(1)(a), (b), (c), (e), (g), (h), (i), and (j). A

 

 1  standardized medicare supplement benefit plan J high deductible

 

 2  plan shall consist of only the following: 100% of covered

 

 3  expenses following the payment of the annual high deductible plan

 

 4  J deductible. The covered expenses include the core benefits as

 

 5  defined in section 3807, plus the medicare part A deductible,

 

 6  skilled nursing facility care, medicare part B deductible, 100%

 

 7  of the medicare part B excess charges, extended outpatient

 

 8  prescription drug benefit, medically necessary emergency care in

 

 9  a foreign country, preventive medical care benefit and at-home

 

10  recovery benefit as defined in section 3809(1)(a), (b), (c), (e),

 

11  (g), (h), (i), and (j). The annual high deductible plan J

 

12  deductible shall consist of out-of-pocket expenses, other than

 

13  premiums, for services covered by the medicare supplement plan J

 

14  policy, and shall be in addition to any other specific benefit

 

15  deductibles. The annual deductible shall be $1,790.00 for

 

16  calendar year 2006, and the secretary shall adjust it annually

 

17  thereafter to reflect the change in the consumer price index for

 

18  all urban consumers for the 12-month period ending with August of

 

19  the preceding year, rounded to the nearest multiple of $10.00.

 

20  The outpatient drug benefit shall not be included in a medicare

 

21  supplement policy sold after December 31, 2005.

 

22        (k) A standardized medicare supplement benefit plan K shall

 

23  consist of only those benefits described in section 3807(2)(a).

 

24        (l) A standardized medicare supplement benefit plan L shall

 

25  consist of only those benefits described in section 3807(2)(b).

 

26        (6) This section applies to medicare supplement policies or

 

27  certificates delivered or issued for delivery on or after June 2,

 

 1  1992 with an effective date for coverage prior to June 1, 2010.

 

 2        Sec. 3811a. (1) This section applies to all medicare

 

 3  supplement policies or certificates delivered or issued for

 

 4  delivery with an effective date for coverage on or after June 1,

 

 5  2010. A policy or certificate shall not be advertised, solicited,

 

 6  delivered, or issued for delivery in this state as a medicare

 

 7  supplement policy or certificate unless it complies with these

 

 8  benefit standards. Benefit plan standards applicable to medicare

 

 9  supplement policies and certificates issued before June 1, 2010

 

10  remain subject to the requirements of section 3811.

 

11        (2) An insurer shall make available to each prospective

 

12  medicare supplement policyholder and certificate holder a policy

 

13  form or certificate form containing only the basic core benefits

 

14  as provided in section 3807a. If an insurer makes available any

 

15  of the additional benefits described in section 3809a or offers

 

16  standardized benefit plans K or L, the insurer shall make

 

17  available to each prospective medicare supplement policyholder

 

18  and certificate holder a policy form or certificate form

 

19  containing either standardized benefit plan C or standardized

 

20  benefit plan F.

 

21        (3) Groups, packages, or combinations of medicare supplement

 

22  benefits other than those listed in this section shall not be

 

23  offered for sale in this state except as may be permitted in

 

24  subsection (6)(k).

 

25        (4) Benefit plans shall be uniform in structure, language,

 

26  designation, and format to the standard benefit plans in

 

27  subsection (6) and shall conform to the definitions in this

 

 1  chapter. Each benefit shall be structured in accordance with

 

 2  sections 3807a and 3809a and list the benefits in the order shown

 

 3  in subsection (6). For purposes of this section, "structure,

 

 4  language, and format" means style, arrangement, and overall

 

 5  content of a benefit.

 

 6        (5) In addition to the benefit plan designations as provided

 

 7  under subsection (6), an insurer may use other designations to

 

 8  the extent permitted by law.

 

 9        (6) A medicare supplement insurance benefit plan shall

 

10  conform to 1 of the following:

 

11        (a) A standardized medicare supplement benefit plan A shall

 

12  be limited to the basic core benefits common to all benefit plans

 

13  as defined in section 3807a.

 

14        (b) A standardized medicare supplement benefit plan B shall

 

15  include only the following: the core benefits as defined in

 

16  section 3807a and 100% of the medicare part A deductible as

 

17  defined in section 3809a(2)(a).

 

18        (c) A standardized medicare supplement benefit plan C shall

 

19  include only the following: the core benefits as defined in

 

20  section 3807a, 100% of the medicare part A deductible, skilled

 

21  nursing facility care, 100% of the medicare part B deductible,

 

22  and medically necessary emergency care in a foreign country as

 

23  defined in section 3809a(2)(a), (c), (d), and (f).

 

24        (d) A standardized medicare supplement benefit plan D shall

 

25  include only the following: the core benefits as defined in

 

26  section 3807a, 100% of the medicare part A deductible, skilled

 

27  nursing facility care, and medically necessary emergency care in

 

 1  a foreign country as defined in section 3809a(2)(a), (c), and

 

 2  (f).

 

 3        (e) A standardized medicare supplement benefit plan F shall

 

 4  include only the following: the core benefits as defined in

 

 5  section 3807a, 100% of the medicare part A deductible, skilled

 

 6  nursing facility care, 100% of the medicare part B deductible,

 

 7  100% of the medicare part B excess charges, and medically

 

 8  necessary emergency care in a foreign country as defined in

 

 9  section 3809a(2)(a), (c), (d), (e), and (f). A standardized

 

10  medicare supplement plan F high deductible shall include only the

 

11  following: 100% of covered expenses following the payment of the

 

12  annual high deductible plan F deductible. The covered expenses

 

13  include the core benefits as defined in section 3807a, plus 100%

 

14  of the medicare part A deductible, skilled nursing facility care,

 

15  100% of the medicare part B deductible, 100% of the medicare part

 

16  B excess charges, and medically necessary emergency care in a

 

17  foreign country as defined in section 3809a(2)(a), (c), (d), (e),

 

18  and (f). The annual high deductible plan F deductible shall

 

19  consist of out-of-pocket expenses, other than premiums, for

 

20  services covered by the medicare supplement plan F policy, and

 

21  shall be in addition to any other specific benefit deductibles.

 

22  The annual high deductible plan F deductible is $1,500.00 for

 

23  calendar year 1999, and the secretary shall adjust it annually

 

24  thereafter to reflect the change in the consumer price index for

 

25  all urban consumers for the 12-month period ending with August of

 

26  the preceding year, rounded to the nearest multiple of $10.00.

 

27        (f) A standardized medicare supplement benefit plan G shall

 

 1  include only the following: the core benefits as defined in

 

 2  section 3807a, 100% of the medicare part A deductible, skilled

 

 3  nursing facility care, 100% of the medicare part B excess

 

 4  charges, and medically necessary emergency care in a foreign

 

 5  country as defined in section 3809a(2)(a), (c), (e), and (f).

 

 6        (g) Standardized medicare supplement benefit plan K shall

 

 7  consist of the following:

 

 8        (i) Coverage of 100% of the part A hospital coinsurance

 

 9  amount for each day used from the sixty-first day through the

 

10  ninetieth day in any medicare benefit period.

 

11        (ii) Coverage of 100% of the part A hospital coinsurance

 

12  amount for each medicare lifetime inpatient reserve day used from

 

13  the ninety-first day through the one hundred fiftieth day in any

 

14  medicare benefit period.

 

15        (iii) Upon exhaustion of the medicare hospital inpatient

 

16  coverage, including the lifetime reserve days, coverage of 100%

 

17  of the medicare part A eligible expenses for hospitalization paid

 

18  at the applicable prospective payment system rate, or other

 

19  appropriate medicare standard of payment, subject to a lifetime

 

20  maximum benefit of an additional 365 days. The provider shall

 

21  accept the insurer's payment as payment in full and may not bill

 

22  the insured for any balance.

 

23        (iv) Medicare part A deductible: coverage for 50% of the

 

24  medicare part A inpatient hospital deductible amount per benefit

 

25  period until the out-of-pocket limitation is met as described in

 

26  subparagraph (x).

 

27        (v) Skilled nursing facility care: coverage for 50% of the

 

 1  coinsurance amount for each day used from the twenty-first day

 

 2  through the one hundredth day in a medicare benefit period for

 

 3  posthospital skilled nursing facility care eligible under

 

 4  medicare part A until the out-of-pocket limitation is met as

 

 5  described in subparagraph (x).

 

 6        (vi) Hospice care: coverage for 50% of cost sharing for all

 

 7  part A medicare eligible expenses and respite care until the out-

 

 8  of-pocket limitation is met as described in subparagraph (x).

 

 9        (vii) Coverage for 50%, under medicare part A or B, of the

 

10  reasonable cost of the first 3 pints of blood or equivalent

 

11  quantities of packed red blood cells, as defined under federal

 

12  regulations, unless replaced in accordance with federal

 

13  regulations until the out-of-pocket limitation is met as

 

14  described in subparagraph (x).

 

15        (viii) Except for coverage provided in subparagraph (ix) below,

 

16  coverage for 50% of the cost sharing otherwise applicable under

 

17  medicare part B after the policyholder pays the part B deductible

 

18  until the out-of-pocket limitation is met as described in

 

19  subparagraph (x).

 

20        (ix) Coverage of 100% of the cost sharing for medicare part B

 

21  preventive services after the policyholder pays the part B

 

22  deductible.

 

23        (x) Coverage of 100% of all cost sharing under medicare

 

24  parts A and B for the balance of the calendar year after the

 

25  individual has reached the out-of-pocket limitation on annual

 

26  expenditures under medicare parts A and B of $4,000.00 in 2006,

 

27  indexed each year by the appropriate inflation adjustment

 

 1  specified by the secretary of the United States department of

 

 2  health and human services.

 

 3        (h) Standardized medicare supplement benefit plan L shall

 

 4  consist of the following:

 

 5        (i) The benefits described in subdivision (g)(i), (ii), (iii),

 

 6  and (ix).

 

 7        (ii) The benefits described in subdivision (g)(iv), (v), (vi),

 

 8  (vii), and (viii), but substituting 75% for 50%.

 

 9        (iii) The benefit described in subdivision (g)(x), but

 

10  substituting $2,000.00 for $4,000.00.

 

11        (i) A standardized medicare supplement benefit plan M shall

 

12  include only the following: the core benefits as defined in

 

13  section 3807a and 50% of the medicare part A deductible, skilled

 

14  nursing care, and medically necessary emergency care in a foreign

 

15  country as defined in section 3809a(2)(b), (c), and (f).

 

16        (j) A standardized medicare supplement benefit plan N shall

 

17  include only the following: the core benefits as defined in

 

18  section 3807a, 100% of the medicare part A deductible, skilled

 

19  nursing facility care, and medically necessary emergency care in

 

20  a foreign country as defined in section 3809a(2)(a), (c), and (f)

 

21  with copayments in the following amounts:

 

22        (i) The lesser of $20.00 or the medicare part B coinsurance

 

23  or copayment for each covered health care provider office visit,

 

24  including visits to medical specialists.

 

25        (ii) The lesser of $50.00 or the medicare part B coinsurance

 

26  or copayment for each covered emergency room visit. The copayment

 

27  shall be waived if the insured is admitted to any hospital and

 

 1  the emergency visit is subsequently covered as a medicare part A

 

 2  expense.

 

 3        (k) New or innovative benefits: an insurer may, with the

 

 4  prior approval of the commissioner, offer policies or

 

 5  certificates with new or innovative benefits in addition to the

 

 6  benefits provided in a policy or certificate that otherwise

 

 7  complies with the applicable standards. The new or innovative

 

 8  benefits may include benefits that are appropriate to medicare

 

 9  supplement insurance, new or innovative, not otherwise available,

 

10  cost-effective, and offered in a manner that is consistent with

 

11  the goal of simplification of medicare supplement policies. The

 

12  innovative benefit shall not include an outpatient prescription

 

13  drug benefit. New or innovative benefits shall not be used to

 

14  change or reduce benefits, including a change of any cost-sharing

 

15  provision, in any standardized plan.

 

16        Sec. 3815. (1) An insurer that offers a medicare supplement

 

17  policy shall provide to the applicant at the time of application

 

18  an outline of coverage and, except for direct response

 

19  solicitation policies, shall obtain an acknowledgment of receipt

 

20  of the outline of coverage from the applicant. The outline of

 

21  coverage provided to applicants pursuant to this section shall

 

22  consist of the following 4 parts:

 

23        (a) A cover page.

 

24        (b) Premium information.

 

25        (c) Disclosure pages.

 

26        (d) Charts displaying the features of each benefit plan

 

27  offered by the insurer.

 

 1        (2) Insurers shall comply with any notice requirements of

 

 2  the medicare prescription drug, improvement, and modernization

 

 3  act of 2003, Public Law 108-173.

 

 4        (3) If an outline of coverage is provided at the time of

 

 5  application and the medicare supplement policy or certificate is

 

 6  issued on a basis that would require revision of the outline, a

 

 7  substitute outline of coverage properly describing the policy or

 

 8  certificate shall accompany the policy or certificate when it is

 

 9  delivered and shall contain the following statement, in no less

 

10  than 12-point type, immediately above the company name:

 

 

11		NOTICE: Read this outline of coverage carefully.
12		It is not identical to the outline of coverage
13		provided upon application and the coverage
14		originally applied for has not been issued.

 

 

15        (4) An outline of coverage under subsection (1) shall be in

 

16  the language and format prescribed in this section and in not

 

17  less than 12-point type. The A through L letter designation of

 

18  the plan shall be shown on the cover page and the plans offered

 

19  by the insurer shall be prominently identified. Premium

 

20  information shall be shown on the cover page or immediately

 

21  following the cover page and shall be prominently displayed. The

 

22  premium and method of payment mode shall be stated for all plans

 

23  that are offered to the applicant. All possible premiums for the

 

24  applicant shall be illustrated. The following items shall be

 

25  included in the outline of coverage in the order prescribed below

 

26  and in substantially the following form, as approved by the

 

 1  commissioner:

 

 

2	(Insurer Name)
3	Medicare Supplement Coverage
4	Outline of Medicare Supplement Coverage-Cover Page:
5	Benefit Plan(s)_____[insert letter(s) of plan(s) being offered]

 

 

 

6	Medicare supplement insurance can be sold in only 12
7	standard plans plus 2 high deductible plans. This chart shows
8	the benefits included in each plan. Every insurer shall make
9	available Plan "A". Some plans may not be available in your
10	state.
11	BASIC BENEFITS: For plans A-J.
12	Hospitalization: Part A coinsurance plus coverage for 365
13	additional days after Medicare benefits end.
14	Medical Expenses: Part B coinsurance (20% of Medicare-approved
15	expenses) or copayments for hospital outpatient services.
16	Blood: First three pints of blood each year.

 

 

 

17		A	B	C	D	E	F|F*	G	H	I	J|J*
18	Basic Benefits	x	x	x	x	x	x	x	x	x	x
19	Skilled Nursing
20	Co-Insurance			x	x	x	x	x	x	x	x
21	Part A Deductible		x	x	x	x	x	x	x	x	x
22	Part B Deductible			x			x				x
23	Part B Excess						x	x		x	x
24							100%	80%		100%	100%
25	Foreign Travel
26	Emergency			x	x	x	x	x	x	x	x
27	At-Home Recovery				x			x		x	x

1
2
3
4	Preventive Care not covered by Medicare					x					x

 

 

 

5	[COMPANY NAME]
6	Outline of Medicare Supplement Coverage – Cover Page 2
7	Basic Benefits for Plans K and L include similar services as
8	plans A-J, but cost-sharing for the basic benefits is at
9	different levels.

 

 

 

10		K**	L**
11	Basic Benefits	100% of Part A	100% of Part A
12		hospitalization	hospitalization
13		coinsurance plus	coinsurance plus
14		coverage for 365 days	coverage for 365 days
15		after Medicare	after Medicare
16		benefits end	benefits end
17		50% Hospice cost-	75% Hospice cost-
18		sharing	sharing
19		50% of Medicare-	75% of Medicare-
20		eligible	eligible
21		expenses for the	expenses for the
22		first three pints	first three pints
23		of blood	of blood
24		50% Part B	75% Part B
25		coinsurance, except	coinsurance, except
26		100% coinsurance for	100% coinsurance for
27		Part B preventive	Part B preventive

1		services	services
2	Skilled Nursing	50% skilled nursing	75% skilled nursing
3	Coinsurance	facility coinsurance	facility coinsurance
4	Part A Deductible	50% Part A deductible	75% Part A deductible
5	Part B Deductible
6	Part B Excess (100%)
7	Foreign Travel
8	Emergency
9	At-Home Recovery
10	Preventive Care not
11	covered by Medicare
12		$4,000 out of pocket	$2,000 out of pocket
13		Annual Limit***	Annual Limit***

 

 

 

14	*Plans F and J also have an option called a high deductible plan F
15	and a high deductible plan J. These high deductible plans pay the
16	same benefits as Plans F and J after one has paid a calendar year
17	($1,790) deductible. Benefits from high deductible Plans F and J
18	will not begin until out-of-pocket expenses exceed ($1,790). Out-
19	of-pocket expenses for this deductible are expenses that would
20	ordinarily be paid by the policy. These expenses include the
21	Medicare deductibles for Part A and Part B, but do not include the
22	plan's separate foreign travel emergency deductible.

 

 

 

23	**Plans K and L provide for different cost-sharing for items and
24	services than Plans A-J.

 

 

 

25	Once you reach the annual limit, the plan pays 100% of the Medicare
26	copayments, coinsurance, and deductibles for the rest of the

1	calendar year. The out-of-pocket annual limit does NOT include
2	charges from your provider that exceed Medicare-approved amounts,
3	called "Excess Charges". You will be responsible for paying excess
4	charges.

 

 

 

5	***The out-of-pocket annual limit will increase each year for
6	inflation.

 

 

 

7	See Outlines of Coverage for details and exceptions.

 

8	BENEFIT CHART OF MEDICARE SUPPLEMENT PLANS SOLD
9	ON OR AFTER JUNE 1, 2010

 

 

10        This chart shows the benefits included in each of the

 

11  standard Medicare supplement plans. Every company must make Plan

 

12  "A" available. Some plans may not be available in your state.

 

13        Plans E, H, I, and J are no longer available for sale. (This

 

14  sentence shall not appear after June 1, 2011.)

 

 

15	BASIC BENEFITS:
16	Hospitalization: Part A coinsurance plus coverage for 365
17	additional days after Medicare benefits end.
18	Medical Expenses: Part B coinsurance (generally 20% of
19	Medicare-approved expenses) or copayments for hospital
20	outpatient services. Plans K, L, and N require insureds
21	to pay a portion of Part B coinsurance or copayments.
22	Blood: First three pints of blood each year.
23	Hospice: Part A coinsurance

 

 

 

1	A	B	C	D	F|F*	G
2	Basic,	Basic,	Basic,	Basic,	Basic,	Basic,
3	including	including	including	including	including	including
4	100% Part	100% Part	100% Part	100% Part	100% Part	100% Part
5	B coin-	B coinsur-	B coinsur-	B coinsur-	B coinsur-	B coinsur-
6	surance	ance	ance	ance	ance	ance
7			Skilled	Skilled	Skilled	Skilled
8			Nursing	Nursing	Nursing	Nursing
9			Facility	Facility	Facility	Facility
10			Coinsur-	Coinsur-	Coinsur-	Coinsur-
11			ance	ance	ance	ance
12		Part A	Part A	Part A	Part A	Part A
13		Deductible	Deductible	Deductible	Deductible	Deductible
14			Part B		Part B
15			Deductible		Deductible
16					Part B	Part B
17					Excess	Excess
18					(100%)	(100%)
19			Foreign	Foreign	Foreign	Foreign
20			Travel	Travel	Travel	Travel
21			Emergency	Emergency	Emergency	Emergency

 

22	K	L	M	N
23	Hospitalization	Hospitalization	Basic,	Basic, includ-
24	and preventive	and preventive	including 100%	ing 100% Part B
25	care paid at	care paid at	Part B	coinsurance,
26	100%; other	100%; other	coinsurance	except up to
27	basic benefits	basic benefits		$20 copayment
28	paid at 50%	paid at 75%		for office
29				visit, and up
30				to $50 copay-

1				ment for ER
2	50% Skilled	75% Skilled	Skilled	Skilled
3	Nursing	Nursing	Nursing	Nursing
4	Facility	Facility	Facility	Facility
5	Coinsurance	Coinsurance	Coinsurance	Coinsurance
6	50% Part A	75% Part A	50% Part A	Part A
7	Deductible	Deductible	Deductible	Deductible
8
9
10
11
12
13			Foreign	Foreign
14			Travel	Travel
15			Emergency	Emergency
16	Out-of-pocket	Out-of-pocket
17	limit $4,140;	limit $2,070;
18	paid at 100%	paid at 100%
19	after limit	after limit
20	reached	reached

 

 

21        * Plan F also has an option called a high-deductible Plan F.

 

22  This high-deductible plan pays the same benefits as Plan F after

 

23  one has paid a calendar year $1,860 deductible. Benefits from

 

24  high-deductible Plan F will not begin until out-of-pocket

 

25  expenses exceed $1,860. Out-of-pocket expenses for this

 

26  deductible are expenses that would ordinarily be paid by the

 

27  policy. These expenses include the Medicare deductibles for Part

 

28  A and Part B, but do not include the plan's separate foreign

 

29  travel emergency deductible.

 

 

1	PREMIUM INFORMATION

 

 

 2        We (insert insurer's name) can only raise your premium if we

 

 3  raise the premium for all policies like yours in this state. (If

 

 4  the premium is based on the increasing age of the insured,

 

 5  include information specifying when premiums will change).

 

 

6	DISCLOSURES

 

 

 7        Use this outline to compare benefits and premiums among

 

 8  policies, certificates, and contracts.

 

 9        This outline shows benefits and premiums of policies sold

 

10  for effective dates on or after June 1, 2010. Policies sold for

 

11  effective dates prior to June 1, 2010 have different benefits and

 

12  premiums. Plans E, H, I, and J are no longer available for sale.

 

13  (This sentence shall not appear after June 1, 2011.)

 

 

14	READ YOUR POLICY VERY CAREFULLY

 

 

15        This is only an outline describing your policy's most

 

16  important features. The policy is your insurance contract. You

 

17  must read the policy itself to understand all of the rights and

 

18  duties of both you and your insurance company.

 

 

19	RIGHT TO RETURN POLICY

 

 

20        If you find that you are not satisfied with your policy, you

 

21  may return it to (insert insurer's address). If you send the

 

 1  policy back to us within 30 days after you receive it, we will

 

 2  treat the policy as if it had never been issued and return all of

 

 3  your payments.

 

 

4	POLICY REPLACEMENT

 

 

 5        If you are replacing another health insurance policy, do not

 

 6  cancel it until you have actually received your new policy and

 

 7  are sure you want to keep it.

 

 

8

NOTICE

 

 

 9        This policy may not fully cover all of your medical costs.

 

10        [For agent issued policies]

 

11        Neither (insert insurer's name) nor its agents are connected

 

12  with medicare.

 

13        [For direct response issued policies]

 

14        (Insert insurer's name) is not connected with medicare.

 

15        This outline of coverage does not give all the details of

 

16  medicare coverage. Contact your local social security office or

 

17  consult "the medicare handbook" for more details.

 

 

18	COMPLETE ANSWERS ARE VERY IMPORTANT

 

 

19        When you fill out the application for the new policy, be

 

20  sure to answer truthfully and completely all questions about your

 

21  medical and health history. The company may cancel your policy

 

22  and refuse to pay any claims if you leave out or falsify

 

23  important medical information. [If the policy or certificate is

 

 1  guaranteed issue, this paragraph need not appear.]

 

 2        Review the application carefully before you sign it. Be

 

 3  certain that all information has been properly recorded.

 

 4        [Include for each plan offered by the insurer a chart

 

 5  showing the services, medicare payments, plan payments, and

 

 6  insured payments using the same language, in the same order, and

 

 7  using uniform layout and format as shown in the charts that

 

 8  follow. An insurer may use additional benefit plan designations

 

 9  on these charts pursuant to section 3809(1)(k). Include an

 

10  explanation of any innovative benefits on the cover page and in

 

11  the chart, in a manner approved by the commissioner. The insurer

 

12  issuing the policy shall change the dollar amounts each year to

 

13  reflect current figures. No more than 4 plans may be shown on 1

 

14  chart.] Charts for each plan are as follows:

 

 

15		PLAN A
16		MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD

 

 

17        *A benefit period begins on the first day you receive

 

18  service as an inpatient in a hospital and ends after you have

 

19  been out of the hospital and have not received skilled care in

 

20  any other facility for 60 days in a row.

 

 

21	SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
22	HOSPITALIZATION*
23	Semiprivate room and
24	board, general nursing
25	and miscellaneous

1	services and supplies
2	First 60 days	All but $952	$0	$952$992
3		$992		(Part A
4				Deductible)
5	61st thru 90th day	All but $238	$238$248	$0
6		$248 a day	a day
7	91st day and after:
8	—While using 60
9	lifetime reserve days	All but $476	$476$496	$0
10		$496 a day	a day
11	—Once lifetime reserve
12	days are used:
13	—Additional 365 days	$0	100% of	$0**
14			Medicare
15			Eligible
16			Expenses
17	—Beyond the
18	Additional 365 days	$0	$0	All Costs
19	SKILLED NURSING FACILITY
20	CARE*
21	You must meet Medicare's
22	requirements, including
23	having been in a hospital
24	for at least 3 days and
25	entered a Medicare-
26	approved facility within
27	30 days after leaving the
28	hospital
29	First 20 days	All approved
30		amounts	$0	$0
31	21st thru 100th day	All but $119	$0	Up to $119

1		$124 a day		$124 a day
2	101st day and after	$0	$0	All costs
3	BLOOD
4	First 3 pints	$0	3 pints	$0
5	Additional amounts	100%	$0	$0
6	HOSPICE CARE
7	Available as long as your	All but very	$0	Balance$0
8	doctor certifies you are	limited	Medicare
9	terminally ill and you	copayment/	copayment/
10	elect to receive these	coinsurance	coinsurance
11	services You must meet	for outpatient
12	Medicare's requirements,	drugs and
13	including a doctor's	inpatient
14	certification of terminal	respite care
15	illness

 

 

16  **NOTICE: When your Medicare Part A hospital benefits are

 

17  exhausted, the insurer stands in the place of Medicare and will

 

18  pay whatever amount Medicare would have paid for up to an

 

19  additional 365 days as provided in the policy's "Core Benefits."

 

20  During this time the hospital is prohibited from billing you for

 

21  the balance based on any difference between its billed charges

 

22  and the amount Medicare would have paid.

 

 

23	PLAN A
24	MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR

 

 

25        *Once you have been billed $124 $131 of Medicare-Approved

 

26  amounts for covered services (which are noted with an asterisk),

 

27  your Part B Deductible will have been met for the calendar year.