19 MAC Pt. 3, R. 10.08.1C
, or offers standardized benefit Plans K or L (as described in
Cite as 19 Miss. Admin. Code Pt. 3, R. 10.08.1C
, or offers standardized benefit Plans K or L (as described in
Rules 10.09.1E(8) and (9) of this regulation), 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 subsection A(1) above, a policy form or certificate form
containing either standardized benefit Plan C (as described in Rule
10.09.1E(3) of this regulation) or standardized benefit Plan F (as described
in Rule 10.09.1E(5) of this regulation).
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 Rule 10.09.1F and in Rule 10.0 of this regulation.
C.
Benefit plans shall be uniform in structure, language, designation and format to the
standard benefit plans listed in this Subsection and conform to the definitions in Rule 10.04 of this
regulation. Each benefit shall be structured in accordance with the format provided in Rules
10.08.1B and 10.08.1C of this regulation; or, in the case of plans K or L, in Rule 10.09.1E(8) or (9)
of this regulation and list the benefits in the order shown. For purposes of this Section, “structure,
language, and format” means style, arrangement and overall content of a benefit.
D.
In addition to the benefit plan designations required in Subsection C of this
section, an issuer may use other designations to the extent permitted by law.
E.
Make‐up of 2010 Standardized Benefit Plans:
1.
Standardized Medicare supplement benefit Plan A shall include only the
following: The basic (core) benefits as defined in Rule 10.08.1B of this regulation.
2.
Standardized Medicare supplement benefit Plan B shall include only the
following: The basic (core) benefit as defined in Rule 10.08.1B of this regulation, plus one
hundred percent (100%) of the Medicare Part A deductible as defined in Rule 10.08.1C(1) of
this regulation.
3.
Standardized Medicare supplement benefit Plan C shall include only the
following: The basic (core) benefit as defined in Rule 10.08.1B of this regulation, plus one
hundred percent (100%) of the Medicare Part A deductible, skilled nursing facility care, one
hundred percent (100%) of the Medicare Part B deductible, and medically necessary
emergency care in a foreign country as defined in Rules 10.08.1C(1), (3), (4), and (6) of this
regulation, respectively.
4.
Standardized Medicare supplement benefit Plan D shall include only the
following: The basic (core) benefit (as defined in Rule 10.08.1B of this regulation), plus one
hundred percent (100%) of the Medicare Part A deductible, skilled nursing facility care, and
medically necessary emergency care in an foreign country as defined in Rule 10.08.1C(1), (3),
and (6) of this regulation, respectively.
5.
Standardized Medicare supplement [regular] Plan F shall include only the
following: The basic (core) benefit as defined in Rule 10.08.1B of this regulation, plus one
hundred percent (100%) of the Medicare Part A deductible, the skilled nursing facility care,
one hundred percent (100%) of the Medicare Part B deductible, one hundred percent (100%)
of the Medicare Part B excess charges, and medically necessary emergency care in a foreign
country as defined in Rule 10.08.1C(1), (3), (4), (5), and (6), respectively.
6.
Standardized Medicare supplement Plan F with High Deductible shall
include only the following: one hundred percent (100%) of covered expenses following the
payment of the annual deductible set forth in Subparagraph (b).
a.
The basic (core) benefit as defined in Rule 10.08.1B of this regulation,
plus one hundred percent (100%) of the Medicare Part A deductible, skilled nursing facility
care, one hundred percent (100%) of the Medicare Part B deductible, one hundred percent
(100%) of the Medicare Part B excess charges, and medically necessary emergency care in a
foreign country as defined in Rule 10.08.1C(1), (3), (4), (5), and (6) of this regulation,
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 the nearest multiple of ten dollars ($10).
7.
Standardized Medicare supplement benefit Plan G shall include only the
following: The basic (core) benefit as defined in Rule 10.08.1B of this regulation, plus one
hundred percent (100%) of the Medicare Part A deductible, skilled nursing facility care, one
hundred percent (100%) of the Medicare Part B excess charges, and medically necessary
emergency care in a foreign country as defined in Rule 10.08.1C(1), (3), (5), and (6),
respectively.
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 61st through 90th days: Coverage of
one hundred percent (100%) of the Part A hospital coinsurance amount for each day used
from the 61st through the 90th day in any Medicare benefit period;
b.
Part A Hospital Coinsurance, 91st through 150th days: Coverage of
one hundred percent (100%) of the Part A hospital coinsurance amount for each Medicare
lifetime inpatient reserve day used from the 91st through the 150th day in any Medicare
benefit period;
c.
Part A Hospitalization After 150 Days: Upon exhaustion of the
Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of one
hundred percent (100%) 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 365 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 fifty percent (50%)
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 fifty percent (50%)
of the coinsurance amount for each day used from the 21st day through the 100th day in a
Medicare benefit period for post‐hospital skilled nursing facility care eligible under
Medicare Part A until the out‐of‐pocket limitation is met as described in Subparagraph (j);
f.
Hospice Care: Coverage for fifty percent (50%) 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 fifty percent (50%), under Medicare Part A or
B, of the reasonable cost of the first three (3) 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 fifty percent (50%) 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 one hundred percent
(100%) 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 one hundred
percent (100%) 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 $4000 in 2006, indexed each year by the
appropriate inflation adjustment specified by the Secretary of the U.S. Department of Health
and Human Services.
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 Paragraphs 9.1E (8) (a), (b), (c) and (i);
b.
The benefit described in Paragraphs 9.1E (8)(d), (e), (f), (g) and
(h), but substituting seventy‐five percent (75%) for fifty percent (50%); and
c.
The benefit described in Paragraph 9.1E(8)(j), but substituting
$2000 for $4000.
10.
Standardized Medicare supplement Plan M shall include only the
following: The basic (core) benefit as defined in Rule 10.08.1B of this regulation, plus fifty
percent (50%) of the Medicare Part A deductible, skilled nursing facility care, and medically
necessary emergency care in a foreign country as defined in Rules 10.08.1C(2), (3) and (6) of
this regulation, respectively.
11.
Standardized Medicare supplement Plan N shall include only the
following: The basic (core) benefit as defined in Rule 10.08.1B of this regulation, plus one
hundred percent (100%) of the Medicare Part A deductible, skilled nursing facility care, and
medically necessary emergency care in a foreign country as defined in Rules 10.08.1C(1), (3)
and (6) of this regulation, respectively, with co‐ payments in the following amounts:
a.
The lesser of twenty dollars ($20) or the Medicare Part B
coinsurance or co‐payment for each covered health care provider office visit (including visits
to medical specialists); and
b.
The lesser of fifty dollars ($50) or the Medicare Part B coinsurance
or co‐ payment for each covered emergency room visit, however, this co‐ payment shall be waived if
the insured is admitted to any hospital and the emergency visit is subsequently covered as a
Medicare Part A expense.
F.
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.