HAR §16-12-5.3. Repealed

[9/3/92] §16-12-5.4 Minimum benefit standards for pre- standardized Medicare supplement benefit plan policies or certificates issued for delivery prior to September 3, 1992. (a) No policy or certificate may be advertised, solicited, or issued for delivery in this State as a Medicare supplement policy or certificate unless it meets or exceeds the minimum standards set forth in this section. These are minimum standards and do not preclude the inclusion of other provisions or benefits which are not inconsistent with these standards. (b) General standards. The following standards apply to Medicare supplement policies and certificates and are in addition to all other requirements of this chapter: (1) A Medicare supplement policy or certificate shall not exclude or limit benefits for losses incurred more than six months from the effective date of coverage because it involved a preexisting condition. The policy or certificate shall 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 months before the effective date of coverage; (2) A Medicare supplement policy or certificate shall not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents; (3) A Medicare supplement policy or certificate shall provide that benefits designed to §16-12-5.4 12-14 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 the changes; (4) A "noncancellable," "guaranteed renewable," or "noncancellable and guaranteed renewable" Medicare supplement policy shall not: (A) 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; or (B) Be cancelled or non-renewed by the issuer solely on the grounds of deterioration of health; (5) (A) Except as authorized by the commissioner of this State, an issuer shall neither cancel nor non-renew a Medicare supplement policy or certificate for any reason other than nonpayment of premium or material misrepresentation; (B) If a group Medicare supplement insurance policy is terminated by the group policyholder and not replaced as provided in subparagraph (D), the issuer shall offer each certificate holder an individual Medicare supplement policy. The issuer shall offer the certificate holder at least the following choices: (i) An individual Medicare supplement policy currently offered by the issuer having comparable benefits to those contained in the terminated group Medicare supplement policy; and §16-12-5.4 12-15 (ii) An individual Medicare supplement policy which provides only those benefits as are required to meet the minimum standards as defined in subsection 16-12-5.6(c) of this chapter; (C) If membership in a group is terminated, the issuer shall: (i) Offer the certificate holder the conversion opportunities as are described in subparagraph (B); or (ii) At the option of the group policyholder, offer the certificate holder continuation of coverage under the group policy; (D) 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 group policy shall not result in any exclusion for preexisting conditions that would have been covered under the group policy being replaced; (6) 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 predicated 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 §16-12-5.4 12-16 Medicare Part D benefits will not be considered in determining a continuous loss. (7) 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 subsection. (c) Minimum benefit standards. (1) Coverage of Medicare Part A eligible expenses for hospitalization to the extent not covered by Medicare from the sixty-first day through the ninetieth day in any Medicare benefit period; (2) Coverage for either all or none of the Medicare Part A inpatient hospital deductible amount; (3) Coverage of Medicare Part A eligible expenses incurred as daily hospital charges during use of Medicare's lifetime hospital inpatient reserve days; (4) Upon exhaustion of all Medicare hospital inpatient coverage including the lifetime reserve days, coverage of 90 per cent of all Medicare Part A eligible expenses for hospitalization not covered by Medicare subject to a lifetime maximum benefit of an additional three hundred sixty-five days; (5) Coverage under Medicare Part A for the reasonable cost of the first three pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulations) unless replaced in accordance with federal regulations or already paid for under Part B; (6) Coverage for the co-insurance amount, or in the case of hospital outpatient department services paid under a prospective payment system, the copayment amount, of Medicare eligible expenses under Part B regardless of §16-12-5.5 12-17 hospital confinement, subject to a maximum calendar year out-of-pocket amount equal to the Medicare Part B deductible [$147]; and (7) Effective January 1, 1990, coverage under Medicare Part B for the reasonable cost of the first three pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulations), unless replaced in accordance with federal regulations or already paid for under Part A, subject to the Medicare deductible amount. [Eff 5/17/82; am and comp 10/28/89; am and comp 12/27/90; am, ren §16-12-6 and comp 9/3/92; am and comp 7/6/99; comp 10/15/01; am and comp 12/9/02; am and comp 10/8/05; am and comp 9/25/09; am and comp 8/1/19] (Auth: HRS §§431:2-201, 431:10A-304, 431:10A-305) (Imp: HRS §§431:2-201, 431:10A-304, 431:10A-305) §16-12-5.5 Benefit standards for 1990 standardized Medicare supplement benefit plan policies or certificates issued or delivered on or after September 3, 1992, and with an effective date for coverage prior to June 1, 2010. (a) The following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this State on or after September 3, 1992, and with an effective date for coverage prior to June 1, 2010 (Exhibit A (revised 2019)). 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. (b) The following are general standards that apply to Medicare supplement policies and certificates and are in addition to all other requirements of this chapter (Exhibit A (revised 2019)): §16-12-5.5 12-18 (1) A Medicare supplement policy or certificate shall not exclude or limit benefits for losses incurred more than six 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 months before the effective date of coverage. (2) A Medicare supplement policy or certificate shall not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents. (3) 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. Premiums may be modified to correspond with those changes. (4) 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. (5) Each Medicare supplement policy shall be guaranteed renewable and: (A) The issuer shall not cancel or non- renew the policy solely on the ground of health status of the individual; (B) The issuer shall not cancel or non- renew the policy for any reason other than nonpayment of premium or material misrepresentation; (C) If the Medicare supplement policy is terminated by the group policyholder and is not replaced as provided under §16-12-5.5 12-19 subparagraph (E), the issuer shall offer certificate holders an individual Medicare supplement policy which (at the option of the certificate holder): (i) Provides for continuation of the benefits contained in the group policy; or (ii) Provides for the benefits that otherwise meet the requirements of this subsection; (D) If an individual is a certificate holder in a group Medicare supplement policy and the individual terminates membership in the group, the issuer shall: (i) Offer the certificate holder the conversion opportunity described in subparagraph (C); or (ii) At the option of the group policyholder, offer the certificate holder continuation of coverage under the group policy; (E) 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; and (F) 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 §16-12-5.5 12-20 guaranteed renewal requirements of this paragraph. (6) 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. (7) (A) 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 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 that assistance. (B) If the suspension occurs and if the policyholder or certificate holder loses entitlement to the medical assistance, the policy or certificate shall be automatically reinstituted (effective as of the date of termination of that entitlement) if the policyholder or certificate holder provides notice of loss of the entitlement within ninety days after §16-12-5.5 12-21 the date of the loss and pays the premium attributable to the period. (C) 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 days after the date of the loss and pays the premium attributable to the period, effective as of the date of termination of entitlement in the group health plan. (D) Reinstitution of the coverages as provided in subparagraphs (B) and (C): (i) Shall not provide for any waiting period with respect to treatment of preexisting conditions; (ii) Shall 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 provided coverage for outpatient prescription drugs, reinstitution of the policy for Medicare Part D enrollees shall be without coverage for §16-12-5.5 12-22 outpatient prescription drugs and shall otherwise provide substantially equivalent coverage to the coverage in effect before the date of suspension; and (iii) 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. (8) 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 16-12-6) to a 2010 standardized plan (as described in section 16-12-6.05), the offer and subsequent exchange shall comply with the following requirements: (A) 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 such 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 §16-12-5.5 12-23 used by an issuer must be filed with the commissioner. (B) The rating class of the new policy or certificate shall be the class closest to the insured's class of the replaced coverage. (C) An issuer may not apply new preexisting 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 preexisting condition limitations of no more than six months to any added benefits contained in the new 2010 standardized policy or certificate not contained in the exchanged policy. (D) 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. (c) The following are standards for basic ("core") benefits common to benefit Plans A-J (Exhibit A (revised 2019)). Every issuer shall make available a policy or certificate including only the following basic "core" package of benefits to each prospective insured. An issuer may make available to prospective insureds any of the other Medicare supplement insurance benefit plans in addition to the basic "core" package, but not in lieu thereof. (1) Coverage of Part A Medicare eligible expenses for hospitalization to the extent not covered by Medicare from the sixty-first day through the ninetieth day in any Medicare benefit period; (2) Coverage of Part A Medicare eligible expenses incurred for hospitalization to the extent not covered by Medicare for each Medicare lifetime inpatient reserve day used; §16-12-5.5 12-24 (3) Upon exhaustion of the Medicare hospital inpatient coverage including the lifetime reserve days, coverage of 100 per cent of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system (PPS) rate, or other appropriate Medicare standard of payment, subject to a lifetime maximum benefit of an additional three hundred sixty-five days. The provider shall accept the issuer's payment as payment in full and may not bill the insured for any balance; (4) Coverage under Medicare Parts A and B for the reasonable cost of the first three pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulations) unless replaced in accordance with federal regulations; and (5) Coverage for the coinsurance amount, or in the case of hospital outpatient department services paid under a prospective payment system, the copayment amount, of Medicare eligible expenses under Part B regardless of hospital confinement, subject to the Medicare Part B deductible. (d) The following are standards for additional benefits. The following additional benefits shall be included in Medicare supplement benefit plans "B" through "J" only as provided by section 16-12-6 (Exhibit A (revised 2019)). (1) Medicare Part A deductible: coverage for all of the Medicare Part A inpatient hospital deductible amount per benefit period; (2) Skilled nursing facility care: coverage for the actual billed charges up to the coinsurance amount from the twenty-first day through the one hundredth day in a Medicare benefit period for post-hospital skilled nursing facility care eligible under Medicare Part A; §16-12-5.5 12-25 (3) Medicare Part B deductible: coverage for all of the Medicare Part B deductible amount per calendar year regardless of hospital confinement; (4) Eighty (80) per cent of the Medicare Part B excess charges: coverage for 80 per cent of the difference between the actual Medicare Part B charge as billed, not to exceed any charge limitation established by the Medicare program or state law, and the Medicare-approved Part B charge; (5) One hundred (100) per cent of the Medicare Part B excess charges: coverage for all of the difference between the actual Medicare Part B charge as billed, not to exceed any charge limitation established by the Medicare program or state law, and the Medicare-approved Part B charge; (6) Basic outpatient prescription drug benefit: coverage for 50 per cent of outpatient prescription drug charges, after a $250 calendar year deductible, to a maximum of $1,250 in benefits received by the insured per calendar year, to the extent not covered by Medicare. The outpatient prescription drug benefit may be included for sale or issuance in a Medicare supplement policy until January 1, 2006; (7) Extended outpatient prescription drug benefit: coverage for 50 per cent of outpatient prescription drug charges, after a $250 calendar year deductible to a maximum of $3,000 in benefits received by the insured per calendar year, to the extent not covered by Medicare. The outpatient prescription drug benefit may be included for sale or issuance in a Medicare supplement policy until January 1, 2006; (8) Medically necessary emergency care in a foreign country: coverage to the extent not covered by Medicare for 80 per cent of the billed charges for Medicare-eligible §16-12-5.5 12-26 expenses for medically necessary emergency hospital, physician and medical care received in a foreign country, which care would have been covered by Medicare if provided in the United States and which care began during the first sixty consecutive days of each trip outside the United States, subject to a calendar year deductible of $250, and a lifetime maximum benefit of $50,000. For purposes of this benefit, "emergency care" shall mean care needed immediately because of an injury or an illness of sudden and unexpected onset; (9) Preventive medical care benefit: coverage for the following preventive health services not covered by Medicare: (A) An annual clinical preventive medical history and physical examination that may include tests and services from subparagraph (B) and patient education to address preventive health care measures; (B) Preventive screening tests or preventive services, the selection and frequency of which is determined to be medically appropriate by the attending physician. Reimbursement shall be for the actual charges up to 100 per cent of the Medicare- approved amount for each service, as if Medicare were to cover the service as identified in American Medical Association Current Procedural Terminology codes, to a maximum of $120 annually under this benefit. This benefit shall not include payment for any procedure covered by Medicare. (10) The following are at-home recovery benefits: coverage for services to provide short term, at-home assistance with activities of daily living for those recovering from an illness, injury, or surgery. §16-12-5.5 12-27 (A) For purposes of this benefit, the following definitions shall apply: "Activities of daily living" include, but are not limited to bathing, dressing, personal hygiene, transferring, eating, ambulating, assistance with drugs that are normally self-administered, and changing bandages or other dressings. "Care provider" means a duly qualified or licensed home health aide or homemaker, personal care aide or nurse provided through a licensed home health care agency or referred by a licensed referral agency or licensed nurses registry. "Home" means any place used by the insured as a place of residence, provided that the place would qualify as a residence for home health care services covered by Medicare. A hospital or skilled nursing facility shall not be considered the insured's place of residence. "At-home recovery visit" means the period of a visit required to provide at-home recovery care, without limit on the duration of the visit, except each consecutive four hours in a twenty-four hour period of services provided by a care provider is one visit. (B) The following are coverage requirements and limitations: At-home recovery services provided must be primarily services which assist in activities of daily living. The insured's attending physician must certify that the specific type and frequency of at-home recovery services are necessary because of a condition for which a home care plan of treatment §16-12-5.5 12-28 was approved by Medicare. Coverage is limited to: (i) No more than the number and type of at-home recovery visits certified as necessary by the insured's attending physician. The total number of at-home recovery visits shall not exceed the number of Medicare-approved home health care visits under a Medicare-approved home care plan of treatment; (ii) The actual charges for each visit up to a maximum reimbursement of $40 per visit; (iii) $1,600 per calendar year; (iv) Seven visits in any one week; (v) Care furnished on a visiting basis in the insured's home; (vi) Services provided by a care provider as defined in this section; (vii) At-home recovery visits while the insured is covered under the policy or certificate and not otherwise excluded; and (viii) At-home recovery visits received during the period the insured is receiving Medicare-approved home care services or no more than eight weeks after the service date of the last Medicare- approved home health care visit. (C) Coverage is excluded for: (i) Home care visits paid for by Medicare or other government programs; and (ii) Care provided by family members, unpaid volunteers, or providers who are not care providers. (e) The following are standards for Plans K and L (Exhibit A (revised 2019)). §16-12-5.5 12-29 (1) Standardized Medicare supplement benefit plan "K" shall consist of the following: (A) Coverage of 100 per cent of the Part A hospital coinsurance amount for each day used from the sixty-first through the ninetieth day in any Medicare benefit period; (B) Coverage of 100 per cent of the Part A hospital coinsurance amount for each Medicare lifetime inpatient reserve day used from the ninety-first through the hundred-fiftieth day in any Medicare benefit period; (C) Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 100 per cent of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system (PPS) rate, or other appropriate Medicare standard of payment, subject to a lifetime maximum benefit of an additional three hundred sixty-five days. The provider shall accept the issuer's payment as payment in full and may not bill the insured for any balance; (D) Medicare Part A deductible: coverage for 50 per cent of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of- pocket limitation is met as described in subparagraph (J); (E) Skilled nursing facility care: coverage for 50 per cent of the coinsurance amount for each day used from the twenty first day through the hundredth day in a Medicare benefit period for post-hospital skilled nursing facility care eligible under Medicare Part A until the out-of-pocket §16-12-5.5 12-30 limitation is met as described in subparagraph (J); (F) Hospice care: coverage for 50 per cent of cost sharing for all Part A Medicare eligible expenses and respite care until the out-of-pocket limitation is met as described in subparagraph (J); (G) Coverage for 50 per cent under Medicare Part A or B, of the reasonable cost of the first three pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulations) unless replaced in accordance with federal regulations until the out-of-pocket limitation is met as described in subparagraph (J); (H) Except for coverage provided in subparagraph (I) below, coverage for 50 per cent of the cost sharing otherwise applicable under Medicare Part B after the policyholder pays the Part B deductible until the out-of-pocket limitation is met as described in subparagraph (J) below; (I) Coverage of 100 per cent of the cost sharing for Medicare Part B preventive services after the policyholder pays the Part B deductible; and (J) Coverage of 100 per cent of all cost sharing under Medicare Parts A and B for the balance of the calendar year after the individual has reached the out-of-pocket limitation on annual expenditures under Medicare Parts A and B of $4,000 in 2006, indexed each year by the appropriate inflation adjustment specified by the secretary of the U.S. Department of Health and Human Services. (2) Standardized Medicare supplement benefit plan "L" shall consist of the following: §16-12-5.6 12-31 (A) The benefits described in subparagraphs (1)(A), (1)(B), (1)(C), and (1)(I) of subsection (e); (B) The benefits described in subparagraphs (1)(D), (1)(E), (1)(F), (1)(G), and (1)(H) of subsection (e), but substituting 75 per cent for 50 per cent; and (C) The benefits described in subparagraph (1)(J) of subsection (e), but substituting $2,000 for $4,000. [Eff and comp 9/3/92; am and comp 7/6/99; am and comp 10/15/01; am and comp 12/9/02; am and comp 10/8/05; am and comp 9/25/09; am and comp 8/1/19] (Auth: HRS §§431:2-201, 431:10A-304, 431:10A-305, 431:10A-306, 431:10A-310) (Imp: HRS §§431:2-201, 431:10A-304, 431:10A-305) §16-12-5.6 Benefit standards for 2010 standardized Medicare supplement benefit plan policies or certificates issued or delivered with an effective date for coverage on or after June 1, 2010. (a) 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 (Exhibit A (revised 2019)). 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 16-12-5.5 or 16-12-6. §16-12-5.6 12-32 (b) General standards. The following standards apply to Medicare supplement policies and certificates and are in addition to all other requirements of this chapter (Exhibit A (revised 2019)). (1) A Medicare supplement policy or certificate shall not exclude or limit benefits for losses incurred more than six 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 months before the effective date of coverage. (2) A Medicare supplement policy or certificate shall not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents. (3) 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. Premiums may be modified to correspond with such changes. (4) 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. (5) Each Medicare supplement policy shall be guaranteed renewable. (A) The issuer shall not cancel or non- renew the policy solely on the ground of health status of the individual. (B) The issuer shall not cancel or non- renew the policy for any reason other §16-12-5.6 12-33 than nonpayment of premium or material misrepresentation. (C) If the Medicare supplement policy is terminated by the group policyholder and is not replaced as provided under subparagraph (E), the issuer shall offer certificate holders an individual Medicare supplement policy which at the option of the certificate holder: (i) Provides for continuation of the benefits contained in the group policy; or (ii) Provides for benefits that otherwise meet the requirements of this subsection. (D) If an individual is a certificate holder in a group Medicare supplement policy and the individual terminates membership in the group, the issuer shall: (i) Offer the certificate holder the conversion opportunity described in subparagraph (C); or (ii) At the option of the group policyholder, offer the certificate holder continuation of coverage under the group policy. (E) 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) Termination of a Medicare supplement policy or certificate shall be without prejudice to §16-12-5.6 12-34 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. (7) (A) 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 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) as of the termination of entitlement if the policyholder or certificate holder provides notice of loss 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. §16-12-5.6 12-35 (C) 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 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. (D) Reinstitution of coverages as described in subparagraphs (B) and (C): (i) Shall not provide for any waiting period with respect to treatment of preexisting conditions; (ii) Shall provide for resumption of coverage that is substantially equivalent to coverage in effect before the date of suspension; and (iii) 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 §16-12-5.6 12-36 holder had the coverage not been suspended. (c) Standards for basic (core) benefits common to Medicare supplement insurance benefit Plans A, B, C, D, F, F with high deductible, G, M, and N. Every issuer of Medicare supplement insurance benefit plans shall make available a policy or certificate including only the following basic "core" package of benefits to each prospective insured (Exhibit A (revised 2019)). An issuer may make available to prospective insureds any of the other Medicare supplement insurance benefit plans in addition to the basic core package, but not in lieu of it: (1) Coverage of Part A Medicare eligible expenses for hospitalization to the extent not covered by Medicare from the sixty-first day through the ninetieth day in any Medicare benefit period; (2) Coverage of Part A Medicare eligible expenses incurred for hospitalization to the extent not covered by Medicare for each Medicare lifetime inpatient reserve day used; (3) Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 100 per cent of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system (PPS) rate, or other appropriate Medicare standard of payment, subject to a lifetime maximum benefit of an additional three hundred sixty-five days. The provider shall accept the issuer's payment as payment in full and may not bill the insured for any balance; (4) Coverage under Medicare Parts A and B for the reasonable cost of the first three pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulations) unless replaced in accordance with federal regulations; §16-12-5.6 12-37 (5) Coverage for the coinsurance amount, or in the case of hospital outpatient department services paid under a prospective payment system, the copayment amount, of Medicare eligible expenses under Part B regardless of hospital confinement, subject to the Medicare Part B deductible; (6) Hospice care: coverage of cost sharing for all Part A Medicare eligible hospice care and respite care expenses. (d) Standards for additional benefits. The following additional benefits shall be included in Medicare supplement benefit Plans B, C, D, F, F with high deductible, G, M, and N as provided by section 16-12-6.05 (Exhibit A (revised 2019)): (1) Medicare Part A deductible: Coverage for 100 per cent of the Medicare Part A inpatient hospital deductible amount per benefit period. (2) Medicare Part A deductible: Coverage for 50 per cent of the Medicare Part A inpatient hospital deductible amount per benefit period. (3) Skilled nursing facility care: Coverage for the actual billed charges up to the coinsurance amount from the twenty-first day through the one hundredth day in a Medicare benefit period for post-hospital skilled nursing facility care eligible under Medicare Part A. (4) Medicare Part B deductible: Coverage for 100 per cent of the Medicare Part B deductible amount per calendar year regardless of hospital confinement. (5) One hundred (100) per cent of the Medicare Part B excess charges: Coverage for all of the difference between the actual Medicare Part B charges as billed, not to exceed any charge limitation established by the Medicare program or state law, and the Medicare-approved Part B charge. §16-12-5.6 12-38 (6) Medically necessary emergency care in a foreign country: coverage to the extent not covered by Medicare for 80 per cent of the billed charges for Medicare-eligible expenses for medically necessary emergency hospital, physician, and medical care received in a foreign country, which care would have been covered by Medicare if provided in the United States and which care began during the first sixty consecutive days of each trip outside the United States, subject to a calendar year deductible of $250, and a lifetime maximum benefit of $50,000. For purposes of this benefit, "emergency care" shall mean care needed immediately because of an injury or an illness of sudden and unexpected onset. [Eff and comp 9/25/09; am and comp 8/1/19] (Auth: HRS §§431:2-201, 431:10A-304, 431:10A-305, 431:10A-309, 431:10A-310) (Imp: HRS §§431:2-201, 431:10A-304, 431:10A-305, 431:10A-309, 431:10A-310) §16-12-6 Standard Medicare supplement benefit plans for 1990 standardized Medicare supplement benefit plan policies or certificates issued or delivered on or after September 3, 1992, and with an effective date for coverage prior to June 1, 2010. (a) An issuer shall make available to each prospective policyholder and certificate holder a policy form or certificate form containing only the basic "core" benefits, as defined in subsection 16-12-5.5(c). (b) No groups, packages, or combinations of Medicare supplement benefits other than those listed in this section shall be offered for sale in this State, except as may be permitted in subsection (g) and section 16-12-6.1. §16-12-6 12-39 (c) Benefit plans shall be uniform in structure, language, designation, and format to the standard benefit plans "A" through "L" listed in subsection (e) and conform to the definitions in section 16-12-3. Each benefit shall be structured in accordance with the format provided in subsections (c) and (d) or (e) of section 16-12-5.5 and list the benefits in the order shown in this subsection (Exhibit A (revised 2019)). For purposes of this section, "structure, language, and format" means style, arrangement, and overall content of a benefit. (d) An issuer may use, in addition to the benefit plan designations required in subsection (c), other designations to the extent permitted by law. (e) The composition of the benefit plans is as follows: (1) Standardized Medicare supplement benefit plan "A" shall be limited to the basic ("core") benefits common to all benefit plans, as defined in subsection 16-12-5.5(c); (2) Standardized Medicare supplement benefit plan "B" shall include only the following: The core benefit as defined in subsection 16-12-5.5(c), plus the Medicare Part A deductible as defined in paragraph 16-12-5.5(d)(1); (3) Standardized Medicare supplement benefit plan "C" shall include only the following: The core benefit as defined in subsection 16-12-5.5(c), plus the Medicare Part A deductible, skilled nursing facility care, Medicare Part B deductible, and medically necessary emergency care in a foreign country as defined in paragraphs 16-12-5.5(d)(1), (2), (3), and (8), respectively; (4) Standardized Medicare supplement benefit plan "D" shall include only the following: The core benefit as defined in subsection 16-12-5.5(c), plus the Medicare Part A §16-12-6 12-40 deductible, skilled nursing facility care, medically necessary emergency care in a foreign country and the at-home recovery benefit as defined in paragraphs 16-12-5.5(d)(1), (2), (8), and (10), respectively; (5) Standardized Medicare supplement benefit plan "E" shall include only the following: The core benefit as defined in subsection 16-12-5.5(c), plus the Medicare Part A deductible, skilled nursing facility care, medically necessary emergency care in a foreign country and preventive medical care as defined in paragraphs 16-12-5.5(d)(1), (2), (8), and (9), respectively; (6) Standardized Medicare supplement benefit plan "F" shall include only the following: The core benefit as defined in subsection 16-12-5.5(c), plus the Medicare Part A deductible, the skilled nursing facility care, the Part B deductible, 100 per cent of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in paragraphs 16-12-5.5(d)(1), (2), (3), (5), and (8), respectively; (7) Standardized Medicare supplement benefit high deductible plan "F" shall include only the following: 100 per cent of covered expenses following the payment of the annual high deductible plan "F" deductible. The covered expenses include the core benefit as defined in subsection 16-12-5.5(c) of this regulation, plus the Medicare Part A deductible, skilled nursing facility care, the Medicare Part B deductible, 100 per cent of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in paragraphs 16-12-5.5(d)(1), (2), (3), (5), and (8), respectively. The annual high deductible plan "F" deductible shall consist of out-of- §16-12-6 12-41 pocket expenses, other than premiums, for services covered by the Medicare supplement plan "F" policy, and shall be in addition to any other specific benefit deductibles. The annual high deductible plan "F" deductible shall be $1,500 for 1998 and 1999, and shall be based on the calendar year. It shall be adjusted annually thereafter by the Secretary to reflect the change in the Consumer Price Index for all urban consumers for the twelve-month period ending with August of the preceding year, and rounded to the nearest multiple of $10; (8) Standardized Medicare supplement benefit plan "G" shall include only the following: The core benefit as defined in subsection 16-12-5.5(c), plus the Medicare Part A deductible, skilled nursing facility care, 80 per cent of the Medicare Part B excess charges, medically necessary emergency care in a foreign country, and the at-home recovery benefit as defined in paragraphs 16-12-5.5(d)(1), (2), (4), (8), and (10), respectively; (9) Standardized Medicare supplement benefit plan "H" shall consist of only the following: The core benefit as defined in subsection 16-12-5.5(c), plus the Medicare Part A deductible, skilled nursing facility care, basic prescription drug benefit, and medically necessary emergency care in a foreign country as defined in paragraphs 16-12-5.5(d)(1), (2), (6), and (8), respectively. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005; (10) Standardized Medicare supplement benefit plan "I" shall consist of only the following: The core benefit as defined in subsection 16-12-5.5(c), plus the Medicare Part A deductible, skilled nursing facility §16-12-6 12-42 care, 100 per cent of the Medicare Part B excess charges, basic prescription drug benefit, medically necessary emergency care in a foreign country, and at-home recovery benefit as defined in paragraphs 16-12-5.5(d)(1), (2), (5), (6), (8), and (10), respectively. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005; (11) Standardized Medicare supplement benefit plan "J" shall consist of only the following: The core benefit as defined in subsection 16-12-5.5(c), plus the Medicare Part A deductible, skilled nursing facility care, Medicare Part B deductible, 100 per cent of the Medicare Part B excess charges, extended prescription drug benefit, medically necessary emergency care in a foreign country, preventive medical care, and at-home recovery benefit as defined in paragraphs 16-12-5.5(d)(1), (2), (3), (5), (7), (8), (9), and (10), respectively. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005; and (12) Standardized Medicare supplement benefit high deductible plan "J" shall consist of only the following: 100 per cent of covered expenses following the payment of the annual high deductible plan "J" deductible. The covered expenses include the core benefit as defined in subsection 16-12-5.5(c) of this regulation, plus the Medicare Part A deductible, skilled nursing facility care, Medicare Part B deductible, 100 per cent of the Medicare Part B excess charges, extended outpatient prescription drug benefit, medically necessary emergency care in a foreign country, preventive medical care benefit, and at-home recovery benefit as defined in paragraphs 16-12-5.5(d)(1), (2), §16-12-6 12-43 (3), (5), (7), (8), (9) and (10), respectively. The annual high deductible plan "J" deductible shall consist of out-of- pocket expenses, other than premiums, for services covered by the Medicare supplement plan "J" policy, and shall be in addition to any other specific benefit deductibles. The annual deductible shall be $1,500 for 1998 and 1999, and shall be based on a calendar year. It shall be adjusted annually thereafter by the Secretary to reflect the change in the Consumer Price Index for all urban consumers for the twelve-month period ending with August of the preceding year, and rounded to the nearest multiple of $10. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005. (f) Make-up of two Medicare supplement plans mandated by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA): (1) Standardized Medicare supplement benefit plan "K" shall consist of only those benefits described in section 16-12- 5.5(e)(1). (2) Standardized Medicare supplement benefit plan "L" shall consist of only those benefits described in section 16-12- 5.5(e)(2). (g) An issuer may, with the prior approval of the commissioner, offer policies or certificates with new or innovative benefits in addition to the benefits provided in a policy or certificate that otherwise complies with the applicable standards. The new or innovative benefits may include benefits that are appropriate to Medicare supplement insurance, new or innovative, not otherwise available, cost-effective, and offered in a manner which is consistent with the goal of simplification of Medicare supplement policies. After December 31, 2005, the innovative benefit shall not include an outpatient prescription §16-12-6 12-44 drug benefit. [Eff and comp 9/3/92; am and comp 7/6/99; comp 10/15/01; comp 12/9/02; am and comp 10/8/05; am and comp 9/25/09; am and comp 8/1/19] (Auth: HRS §§431:2-201, 431:10A-304, 431:10A-305, 431:10A-309) (Imp: HRS §§431:2-201, 431:10A-304, 431:10A-305, 431:10A-309) §16-12-6.05 Standard Medicare supplement benefit plans for 2010 standardized Medicare supplement benefit plan policies or certificates issued or delivered with an effective date for coverage on or after June 1, 2010. (a) 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 plan standards. Benefit plan standards applicable to Medicare supplement policies and certificates issued with an effective date for coverage before June 1, 2010, remain subject to the requirements of sections 16-12-5.5 or 16-12-6. (b) (1) An issuer shall make available to each prospective policyholder and certificate holder a policy form or certificate form containing only the basic (core) benefit, as defined in section 16-12-5.6(c). (2) If an issuer makes available any of the additional benefits described in section 16-12-5.6(d) or offers standardized benefit Plans K or L (as described in paragraphs (f)(8) or (f)(9)), then the issuer shall make available to each prospective policyholder and certificate holder, in addition to a policy form or certificate form with only the basic (core) benefits as described in paragraph (b)(1), a policy form or certificate form containing either §16-12-6.05 12-45 standardized benefit Plan C (as described in paragraph (f)(3)) or standardized benefit Plan F (as described in paragraph (f)(5)). (c) No groups, packages, or combinations of Medicare supplement benefits other than those listed in this section shall be offered for sale in this State, except as may be permitted in subsection (g) and in section 16-12-6.1. (d) Benefit plans shall be uniform in structure, language, designation, and format to the standard benefit plans listed in this section and conform to the definitions in section 16-12-3. Each benefit shall be structured in accordance with the format provided in sections 16-12-5.6(c) and 16-12-5.6(d); or, in the case of Plans K or L, in paragraphs (f)(8) or (f)(9), and list the benefits in the order shown (Exhibit A (revised 2019)). For purposes of this section, "structure, language, and format" means style, arrangement, and overall content of a benefit. (e) In addition to the benefit plan designations required in subsection (d), an issuer may use other designations to the extent permitted by law. (f) Make-up of 2010 standardized benefit plans (Exhibit A (revised 2019)): (1) Standardized Medicare supplement benefit Plan A shall include only the following: The basic (core) benefits as defined in subsection 16-12-5.6(c). (2) Standardized Medicare supplement benefit Plan B shall include only the following: The basic (core) benefit as defined in subsection 16-12-5.6(c), plus 100 per cent of the Medicare Part A deductible as defined in paragraph 16-12-5.6(d)(1). (3) Standardized Medicare supplement benefit Plan C shall include only the following: The basic (core) benefit as defined in subsection 16-12-5.6(c), plus 100 per cent of the Medicare Part A deductible, skilled nursing facility care, 100 per cent of the Medicare Part B deductible, and medically necessary emergency care in a foreign §16-12-6.05 12-46 country as defined in paragraphs 16-12- 5.6(d)(1), 16-12-5.6(d)(3), 16-12-5.6(d)(4), and 16-12-5.6(d)(6), respectively. (4) Standardized Medicare supplement benefit Plan D shall include only the following: The basic (core) benefit as defined in subsection 16-12-5.6(c), plus 100 per cent of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in paragraphs 16-12- 5.6(d)(1), 16-12-5.6(d)(3), and 16-12- 5.6(d)(6), respectively. (5) Standardized Medicare supplement (regular) Plan F shall include only the following: The basic (core) benefit as defined in subsection 16-12-5.6(c), plus 100 per cent of the Medicare Part A deductible, skilled nursing facility care, 100 per cent of the Medicare Part B deductible, 100 per cent of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in paragraphs 16- 12-5.6(d)(1), 16-12-5.6(d)(3), 16-12- 5.6(d)(4), 16-12-5.6(d)(5), and 16-12- 5.6(d)(6), respectively. (6) Standardized Medicare supplement Plan F with high deductible shall include only the following: 100 per cent of covered expenses following the payment of the annual deductible set forth in subparagraph (B). (A) The basic (core) benefit as defined in subsection 16-12-5.6(c), plus 100 per cent of the Medicare Part A deductible, skilled nursing facility care, 100 per cent of the Medicare Part B deductible, 100 per cent of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in paragraphs 16-12-5.6(d)(1), 16-12-5.6(d)(3), 16-12-5.6(d)(4), 16- §16-12-6.05 12-47 12-5.6(d)(5), and 16-12-5.6(d)(6), respectively. (B) The annual deductible in Plan F with high deductible shall consist of out- of-pocket expenses, other than premiums, for services covered by (regular) Plan F, and shall be in addition to any other specific benefit deductibles. The basis for the deductible shall be $1,500 and shall be adjusted annually from 1999 by the Secretary of the U.S. Department of Health and Human Services to reflect the change in the Consumer Price Index for all urban consumers for the twelve- month period ending with August of the preceding year, and rounded to nearest multiple of $10. (7) Standardized Medicare supplement benefit Plan G shall include only the following: The basic (core) benefit as defined in subsection 16-12-5.6(c), plus 100 per cent of the Medicare Part A deductible, skilled nursing facility care, 100 per cent of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in paragraphs 16- 12-5.6(d)(1), 16-12-5.6(d)(3), 16-12- 5.6(d)(5), and 16-12-5.6(d)(6), respectively. Effective January 1, 2020, the standardized benefit plans described in section 16-12-6.06(b)(4) (redesignated Plan G with high deductible) may be offered to any individual who was eligible for Medicare prior to January 1, 2020. (8) Standardized Medicare supplement Plan K is mandated by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, and shall include only the following: (A) Part A hospital coinsurance, sixty- first through ninetieth days: Coverage of 100 per cent of the Part A hospital §16-12-6.05 12-48 coinsurance amount for each day used from the sixty-first through the ninetieth day in any Medicare benefit period; (B) Part A hospital coinsurance, ninety- first through one-hundred fiftieth days: Coverage of 100 per cent of the Part A hospital coinsurance amount for each Medicare lifetime inpatient reserve day used from the ninety-first through the one-hundred fiftieth day in any Medicare benefit period; (C) Part A hospitalization after one hundred fifty days: Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 100 per cent of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system (PPS) rate, or other appropriate Medicare standard of payment, subject to a lifetime maximum benefit of an additional three hundred sixty-five days. The provider shall accept the issuer's payment as payment in full and may not bill the insured for any balance; (D) Medicare Part A deductible: Coverage for 50 per cent of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of- pocket limitation is met as described in subparagraph (J); (E) Skilled nursing facility care: coverage for 50 per cent of the coinsurance amount for each day used from the twenty-first day through the one hundredth day in a Medicare benefit period for post-hospital skilled nursing facility care eligible under Medicare Part A until the out-of-pocket §16-12-6.05 12-49 limitation is met as described in subparagraph (J); (F) Hospice care: Coverage for 50 per cent of cost sharing for all Part A Medicare eligible expenses and respite care until the out-of-pocket limitation is met as described in subparagraph (J); (G) Blood: Coverage for 50 per cent under Medicare Part A or B, of the reasonable cost of the first three pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulations) unless replaced in accordance with federal regulations until the out-of-pocket limitation is met as described in subparagraph (J); (H) Part B cost sharing: Except for coverage provided in subparagraph (I), coverage for 50 per cent of the cost sharing otherwise applicable under Medicare Part B after the policyholder pays the Part B deductible until the out-of-pocket limitation is met as described in subparagraph (J); (I) Part B preventive services: Coverage of 100 per cent of the cost sharing for Medicare Part B preventive services after the policyholder pays the Part B deductible; and (J) Cost sharing after out-of-pocket limits: Coverage of 100 per cent of all cost sharing under Medicare Parts A and B for the balance of the calendar year after the individual has reached the out-of-pocket limitation on annual expenditures under Medicare Parts A and B of $4,000 in 2006, indexed each year by the appropriate inflation adjustment specified by the Secretary of the U.S. Department of Health and Human Services §16-12-6.05 12-50 (9) Standardized Medicare supplement Plan L is mandated by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, and shall include only the following: (A) The benefits described in subparagraphs (f)(8)(A), (f)(8)(B), (f)(8)(C), and (f)(8)(I); (B) The benefits described in subparagraphs (f)(8)(D), (f)(8)(E), (f)(8)(F), (f)(8)(G), and (f)(8)(H) but substituting 75 per cent for 50 per cent; and (C) The benefit described in subparagraph (f)(8)(J), but substituting $2,000 for $4,000. (10) Standardized Medicare supplement Plan M shall include only the following: The basic (core) benefit as defined in subsection 16- 12-5.6(c), plus 50 per cent of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in paragraphs 16-12-5.6(d)(2), 16-12-5.6(d)(3), and 16-12-5.6(d)(6). (11) Standardized Medicare supplement Plan N shall include only the following: The basic (core) benefit as defined in subsection 16- 12-5.6(c), plus 100 per cent of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in paragraphs 16-12-5.6(d)(1), 16-12-5.6(d)(3), and 16-12-5.6(d)(6) with copayments in the following amounts: (A) The lesser of $20 or the Medicare Part B coinsurance or copayment for each covered health care provider office visit (including visits to medical specialists); and (B) The lesser of $50 or the Medicare Part B coinsurance or copayment for each §16-12-6.06 12-51 covered emergency room visit, however, this copayment shall be waived if the insured is admitted to any hospital and the emergency visit is subsequently covered as a Medicare Part A expense. (g) New or innovative benefits: An issuer may, with the prior approval of the commissioner, offer policies or certificates with new or innovative benefits, in addition to the standardized benefits provided in a policy or certificate that otherwise complies with the applicable standards. The new or innovative benefits shall include only benefits that are appropriate to Medicare supplement insurance, are new or innovative, are not otherwise available, and are cost-effective. Approval of new or innovative benefits must not adversely impact the goal of Medicare supplement simplification. New or innovative benefits shall not include an outpatient prescription drug benefit. New or innovative benefits shall not be used to change or reduce benefits, including a change of any cost-sharing provision, in any standardized plan. [Eff and comp 9/25/09; am and comp 8/1/19] (Auth: HRS §§431:2-201, 431:10A-304, 431:10A-305, 431:10A-309, 431:10A-310) (Imp: HRS §§431:2-201, 431:10A-304, 431:10A-305, 431:10A-309, 431:10A-310) §16-12-6.06 Standard Medicare supplement benefit plans for 2020 standardized Medicare supplement benefit plan policies or certificates issued for delivery to individuals newly eligible for Medicare on or after January 1, 2020. (a) No policy or certificate that provides coverage of the Medicare Part B deductible may be advertised, solicited, delivered, or issued for delivery in this State as a Medicare supplement policy or certificate to individuals newly eligible for Medicare on or after January 1, 2020. All policies must comply with the following benefit standards. Benefit plan standards applicable to Medicare supplement policies and §16-12-6.06 12-52 certificates issued to individuals eligible for Medicare before January 1, 2020, remain subject to the requirements of sections 16-12-5.5, 16-12-6, and 16- 12-6.05. (b) Benefit requirements. The standards and requirements of section 16-12-6.05 shall apply to all Medicare supplement policies or certificates delivered or issued for delivery to individuals newly eligible for Medicare on or after January 1, 2020, with the following exceptions: (1) Standardized Medicare supplement benefit Plan C is redesignated as Plan D and shall provide the benefits contained in section 16-12-6.05(f)(3) but shall not provide coverage for 100 per cent or any portion of the Medicare Part B deductible. (2) Standardized Medicare supplement benefit Plan F is redesignated as Plan G and shall provide the benefits contained in section 16-12-6.05(f)(5) but shall not provide coverage for 100 per cent or any portion of the Medicare Part B deductible. (3) Standardized Medicare supplement benefit Plans C, F, and F with high deductible may not be offered to individuals newly eligible for Medicare on or after January 1, 2020. (4) Standardized Medicare supplement benefit Plan F with high deductible is redesignated as Plan G with high deductible and shall provide the benefits contained in section 16-12-6.05(f)(6) of this regulation but shall not provide coverage for 100 per cent or any portion of the Medicare Part B deductible; provided further that, the Medicare Part B deductible paid by the beneficiary shall be considered an out-of- pocket expense in meeting the annual high deductible. (5) The reference to Plans C or F contained in section 16-12-6.05(b)(2) is deemed a reference to Plans D or G for purposes of this section. §16-12-6.06 12-53 (c) Applicability to certain individuals. This section applies to only individuals that are newly eligible for Medicare on or after January 1, 2020: (1) By reason of attaining age 65 on or after January 1, 2020; or (2) By reason of entitlement to benefits under Part A pursuant to Section 226(b) or 226A of the Social Security Act, or who is deemed to be eligible for benefits under Section 226(a) of the Social Security Act on or after January 1, 2020. (d) Guaranteed issue for eligible persons. For purposes of section 16-12-6.3(e), in the case of any individual newly eligible for Medicare on or after January 1, 2020, any reference to a Medicare supplement policy C or F (including F with high deductible) shall be deemed to be a reference to Medicare supplement policy D or G (including G with high deductible), respectively, that meets the requirements of subsection (b). (e) Applicability to waivered states. In the case of a state described in Section 1882(p)(6) of the Social Security Act ("waivered" alternative simplification states) the Medicare Access and CHIP Reauthorization Act of 2015 prohibits the coverage of the Medicare Part B deductible for any Medicare supplement policy sold or issued to an individual that is newly eligible for Medicare on or after January 1, 2020. (f) Offer of redesignated plans to individuals other than newly eligible. On or after January 1, 2020, the standardized benefit plans described in subsection (b)(4) may be offered to any individual who was eligible for Medicare prior to January 1, 2020, in addition to the standardized plans described in section 16-12-6.05(f). [Eff and comp 8/1/19] (Auth: HRS §§431:2-201, 431:10A-304, 431:10A-305, 431:10A-309, 431:10A-310) (Imp: HRS §§431:2-201, 431:10A-304, 431:10A-305, 431:10A-309, 431:10A-310) §16-12-6.1 12-54 §16-12-6.1 Medicare Select policies and certificates. (a)(1) This section shall apply to Medicare Select policies and certificates, as defined in this section. (2) No policy or certificate may be advertised as a Medicare Select policy or certificate unless it meets the requirements of this section. (b) For the purposes of this section: "Complaint" means any dissatisfaction expressed by an individual concerning a Medicare Select issuer or its network providers. "Grievance" means dissatisfaction expressed in writing by an individual insured under a Medicare Select policy or certificate with the administration, claims practices, or provision of services concerning a Medicare Select issuer or its network providers. "Medicare Select issuer" means an issuer offering, or seeking to offer, a Medicare Select policy or certificate. "Medicare Select policy" or "Medicare Select certificate" mean respectively a Medicare supplement policy or certificate that contains restricted network provisions. "Network provider" means a provider of health care, or a group of providers of health care, which has entered into a written agreement with the issuer to provide benefits insured under a Medicare Select policy. "Restricted network provision" means any provision which conditions the payment of benefits, in whole or in part, on the use of network providers. "Service area" means the geographic area approved by the commissioner within which an issuer is authorized to offer a Medicare Select policy. (c) The commissioner may authorize an issuer to offer a Medicare Select policy or certificate, pursuant to this section and Section 4358 of the Omnibus Budget Reconciliation Act (OBRA) of 1990 if §16-12-6.1 12-55 the commissioner finds that the issuer has satisfied all of the requirements of this regulation. (d) A Medicare Select issuer shall not issue a Medicare Select policy or certificate in this State until its plan of operation has been approved by the commissioner. (e) A Medicare Select issuer shall file a proposed plan of operation with the commissioner in a format prescribed by the commissioner. The plan of operation shall contain at least the following information: (1) Evidence that all covered services that are subject to restricted network provisions are available and accessible through network providers, including a demonstration that: (A) The services can be provided by network providers with reasonable promptness with respect to geographic location, hours of operation, and after-hour care. The hours of operation and availability of after-hour care shall reflect usual practice in the local area. Geographic availability shall reflect the usual travel times within the community. (B) The number of network providers in the service area is sufficient, with respect to current and expected policyholders, either: (i) To deliver adequately all services that are subject to a restricted network provision; or (ii) To make appropriate referrals. (C) There are written agreements with network providers describing specific responsibilities. (D) Emergency care is available twenty-four hours per day and seven days per week. (E) In the case of covered services that are subject to a restricted network provision and are provided on a prepaid basis, there are written agreements §16-12-6.1 12-56 with network providers prohibiting the providers from billing or otherwise seeking reimbursement from or recourse against any individual insured under a Medicare Select policy or certificate. This paragraph shall not apply to supplemental charges or coinsurance amounts as stated in the Medicare Select policy or certificate. (2) A statement or map providing a clear description of the service area; (3) A description of the grievance procedure to be utilized; (4) A description of the quality assurance program, including: (A) The formal organizational structure; (B) The written criteria for selection, retention, and removal of network providers; and (C) The procedures for evaluating quality of care provided by network providers, and the process to initiate corrective action when warranted. (5) A list and description, by specialty, of the network providers. (6) Copies of the written information proposed to be used by the issuer to comply with subsection (i) of this section; and (7) Any other information requested by the commissioner. (f) (1) A Medicare Select issuer shall file any proposed changes to the plan of operation, except for changes to the list of network providers, with the commissioner prior to implementing the changes. The changes shall be considered approved by the commissioner after thirty days unless specifically disapproved. (2) An updated list of network providers shall be filed with the commissioner at least quarterly. §16-12-6.1 12-57 (g) A Medicare Select policy or certificate shall not restrict payment for covered services provided by non-network providers if: (1) The services are for symptoms requiring emergency care or are immediately required for an unforeseen illness, injury, or a condition; and (2) It is not reasonable to obtain the services through a network provider. (h) A Medicare Select policy or certificate shall provide payment for full coverage under the policy for covered services that are not available through network providers. (i) A Medicare Select issuer shall make full and fair disclosure in writing of the provisions, restrictions, and limitations of the Medicare Select policy or certificate to each applicant. This disclosure shall include at least the following: (1) An outline of coverage sufficient to permit the applicant to compare the coverage and premiums of the Medicare Select policy or certificate with: (A) Other Medicare supplement policies or certificates offered by the issuer; and (B) Other Medicare Select policies or certificates. (2) A description (including address, phone number, and hours of operation) of the network providers, including primary care physicians, specialty physicians, hospitals, and other providers. (3) A description of the restricted network provisions, including payments for coinsurance and deductibles when providers other than network providers are utilized. Except to the extent specified in the policy or certificate, expenses incurred when using out-of-network providers do not count toward the out-of-pocket annual limit contained in Plans K and L. §16-12-6.1 12-58 (4) A description of coverage for emergency and urgently needed care and other out-of- service area coverage. (5) A description of limitations on referrals to restricted network providers and to other providers. (6) A description of the policyholder’s rights to purchase any other Medicare supplement policy or certificate otherwise offered by the issuer. (7) A description of the Medicare Select issuer’s quality assurance program and grievance procedure. (j) Prior to the sale of a Medicare Select policy or certificate, a Medicare Select issuer shall obtain from the applicant a signed and dated form stating that the applicant has received the information provided pursuant to subsection (i) of this section and that the applicant understands the restrictions of the Medicare Select policy or certificate. (k) A Medicare Select issuer shall have and use procedures for hearing complaints and resolving written grievances from the subscribers. The procedures shall be aimed at mutual agreement for settlement and may include arbitration procedures. (1) The grievance procedure shall be described in the policy and certificates and in the outline of coverage; (2) At the time the policy or certificate is issued, the issuer shall provide detailed information to the policyholder describing how a grievance may be registered with the issuer; (3) Grievances shall be considered in a timely manner and shall be transmitted to appropriate decision-makers who have authority to fully investigate the issue and take corrective action; (4) If a grievance is found to be valid, corrective action shall be taken promptly; §16-12-6.1 12-59 (5) All concerned parties shall be notified about the results of a grievance; and (6) The issuer shall report no later than each March 31st to the commissioner regarding its grievance procedure. The report shall be in a format prescribed by the commissioner and shall contain the number of grievances filed in the past year and a summary of the subject, nature, and resolution of the grievances. (l) At the time of initial purchase, a Medicare Select issuer shall make available to each applicant for a Medicare Select policy or certificate the opportunity to purchase any Medicare supplement policy or certificate otherwise offered by the issuer. (m) (1) At the request of an individual insured under a Medicare Select policy or certificate, a Medicare Select issuer shall make available to the individual insured the opportunity to purchase a Medicare supplement policy or certificate offered by the issuer which has comparable or lesser benefits and which does not contain a restricted network provision. The issuer shall make the policies or certificates available without requiring evidence of insurability after the Medicare Select policy or certificate has been in force for six months. (2) For the purposes of this subsection, a Medicare supplement policy or certificate will be considered to have comparable or lesser benefits unless it contains one or more significant benefits not included in the Medicare Select policy or certificate being replaced. For the purposes of this paragraph, a significant benefit means coverage for the Medicare Part A deductible, coverage for at-home recovery services, or coverage for Part B excess charges. §16-12-6.1 12-60 (n) Medicare Select policies and certificates shall provide for continuation of coverage in the event the Secretary of Health and Human Services determines that Medicare Select policies and certificates issued pursuant to this section should be discontinued due to either the failure of the Medicare Select program to be reauthorized under law or its substantial amendment. (1) Each Medicare Select issuer shall make available to each individual insured under a Medicare Select policy or certificate the opportunity to purchase any Medicare supplement policy or certificate offered by the issuer which has comparable or lesser benefits and which does not contain a restricted network provision. The issuer shall make the policies and certificates available without requiring evidence of insurability. (2) For the purposes of this subsection, a Medicare supplement policy or certificate will be considered to have comparable or lesser benefits unless it contains one or more significant benefits not included in the Medicare Select policy or certificate being replaced. For the purposes of this paragraph, a significant benefit means coverage for the Medicare Part A deductible, coverage for at-home recovery services or coverage for Part B excess charges. (o) A Medicare Select issuer shall comply with reasonable requests for data made by state or federal agencies, including the United States Department of Health and Human Services, for the purpose of evaluating the Medicare Select program. [Eff and comp 7/6/99; comp 10/15/01; comp 12/9/02; am and comp 10/8/05; comp 9/25/09; am and comp 8/1/19] (Auth: HRS §§431:2-201, 431:10A-304, 431:10A-305) (Imp: HRS §§431:2-201, 431:10A-304, 431:10A-305) §16-12-6.2 12-61