Except as otherwise provided in Regulations .10, .11, and .17 of this chapter, this chapter applies to all: Medicare supplement policies delivered or issued for delivery in this State; and Certificates issued under group Medicare supplement policies if the certificates are delivered or issued for delivery in this State. This chapter is applicable to all Medicare supplement policies and certificates under group Medicare supplement policies held by residents of this State and in force on the day preceding the effective date of House Bill 305 (Chapter 526, Acts of 1992), except as to the benefits and other policy provisions of those policies and certificates. While those policies and certificates remain in effect, their benefits and policy provisions shall continue to be governed by the applicable provisions of the Annotated Code of Maryland in effect immediately preceding the effective date of House Bill 305 (Chapter 526, Acts of 1992) and of the applicable regulations of COMAR 31.10.05 where the latter regulations are inconsistent with this chapter. This chapter does not apply to a policy or a certificate under a group policy issued to one or more employers or labor organizations, or to the trustees of a fund established by one or more employers or labor organizations for employees or former employees of the employers, or for members or former members of the labor organizations. In this chapter, the following terms have the meanings indicated. Terms Defined. “Adverse decision” has the meaning stated in Insurance Article, §15-10A-01, Annotated Code of Maryland. “Applicant” means: In the case of an individual Medicare supplement policy, the person who seeks to contract for insurance benefits; and In the case of a group Medicare supplement policy, the proposed certificate holder. “Bankruptcy” means when a Medicare Advantage organization that is not an issuer has filed, or has had filed against it, a petition for declaration of bankruptcy and has ceased doing business in the State. “Certificate” means any certificate delivered or issued for delivery in this State under a group Medicare supplement policy. “Certificate form” means the form on which the certificate is delivered or issued for delivery by the issuer. “Complaint” means any dissatisfaction expressed by an individual concerning a Medicare Select issuer or its network providers. “Continuous period of creditable coverage” means the period during which an individual was covered by creditable coverage, if during the period of the coverage the individual had no breaks in coverage greater than 63 days. “Coverage decision” has the meaning stated in Insurance Article, §15-10D-01, Annotated Code of Maryland. Creditable coverage. “Creditable coverage” means, with respect to an individual, coverage of the individual provided under any of the following: A group health plan; Health insurance coverage; Part A or Part B of Title XVIII of the Social Security Act (Medicare); Title XIX of the Social Security Act (Medicaid), other than coverage consisting solely of benefits under §1928; Chapter 55 of Title 10 United States Code (CHAMPUS); A medical care program of the Indian Health Service or of a tribal organization; A State health benefits risk pool; A health plan offered under Chapter 89 of Title 5 United States Code (Federal Employees Health Benefits Program); A public health plan as defined in federal regulation; and A health benefit plan under §5(e) of the Peace Corps Act (22 U.S.C. §2504(e)). “Creditable coverage” does not include one or more, or any combination of, the following: Coverage only for accident or disability income insurance, or any combination of them; Coverage issued as a supplement to liability insurance; Liability insurance, including general liability insurance and automobile liability insurance; Workers' compensation or similar insurance; Automobile medical payment insurance; Credit-only insurance; Coverage for on-site medical clinics; and Other similar insurance coverage, specified in federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits. “Creditable coverage” does not include coverage for the following benefits if they are provided under a separate policy, certificate, or contract of insurance, or are otherwise not an integral part of a plan of coverage described in §B(9)(a) of this regulation: Limited scope dental or vision benefits; Benefits for long-term care, nursing home care, home health care, community-based care, or any combination of these coverages; and Other similar, limited benefits as are specified in federal regulations. “Creditable coverage” does not include coverage for the following benefits if offered as independent, noncoordinated benefits: Coverage only for a specified disease or illness; and Hospital indemnity or other fixed indemnity insurance. “Creditable coverage” does not include the following coverage if it is offered as a separate policy, certificate, or contract of insurance: Medicare supplemental health insurance as defined under §1882(g)(1) of the Social Security Act; Coverage supplemental to the coverage provided under Chapter 55 of Title 10, United States Code; and Similar supplemental coverage provided to coverage under a group health plan. “Employee welfare benefit plan” means a plan, fund, or program of employee benefits as defined in 29 U.S.C. §1002 (Employee Retirement Income Security Act). “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. “Insolvency” means when an issuer, licensed to transact the business of insurance in this State, has had a final order of liquidation entered against it with a finding of insolvency by a court of competent jurisdiction in the issuer's state of domicile. “Issuer” means insurance companies, fraternal benefit societies, nonprofit health service plans, health maintenance organizations, and any other entity delivering or issuing for delivery in this State Medicare supplement policies or certificates. “Medicare” means the Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965, as then constituted or later amended. Medicare Advantage Plan. “Medicare Advantage plan” means a plan of coverage for health benefits under Medicare Part C as defined in 42 U.S.C. §1395w-28(b)(1). “Medicare Advantage plan” includes: Coordinated care plans that provide health care services, including health maintenance organization plans (with or without a point-of-service option), plans offered by provider-sponsored organizations, and preferred provider organization plans; Medical savings account plans coupled with a contribution into a Medicare Advantage Plan medical savings account; and Medicare Advantage private fee-for-service plans. “Medicare Select certificate” means a Medicare supplement certificate that contains restricted network provisions. “Medicare Select issuer” means an issuer offering, or seeking to offer, a Medicare Select policy or certificate. “Medicare Select policy” means a Medicare supplement policy that contains restricted network provisions. Medicare Supplement Policy. “Medicare supplement policy” means a group or individual policy of health insurance, or a certificate of a fraternal benefit society, or a subscriber contract of a nonprofit health service plan or of a health maintenance organization, other than a policy issued pursuant to a contract under the federal Social Security Act, §1876, or an issued policy under a demonstration project specified in 42 U.S.C. §1395ss(g)(1), which is advertised, marketed, or designed primarily as a supplement to reimbursements under Medicare for the hospital, medical, or surgical expenses of persons eligible for Medicare. “Medicare supplement policy” does not include Medicare Advantage plans established under Medicare Part C, Outpatient Prescription Drug plans established under Medicare Part D, or any Health Care Prepayment Plan (HCPP) that provides benefits pursuant to an agreement under §1833(a)(1)(A) of the Social Security Act. “Network provider” means a provider, or 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. “Newly eligible for Medicare” means the individual: Attained age 65; or Became entitled to benefits under part A pursuant to §226(b) or 226A of the Social Security Act, or is deemed to be eligible for benefits under §226(a) of the Social Security Act. 1990 standardized Medicare Supplement Benefit Plan. “1990 standardized Medicare supplement benefit plan”, “1990 standardized benefit plan”, or “1990 plan” means a group or individual policy of Medicare supplement insurance issued on or after July 14, 1992, and with an effective date for coverage before June 1, 2010. “1990 standardized Medicare supplement benefit plan”, “1990 standardized benefit plan”, or “1990 plan” includes Medicare supplement insurance policies and certificates described in §B(21)(a) of this regulation that are renewed on or after June 1, 2010, which are not replaced by the issuer at the request of the insured. “Policy form” means the form on which the policy or certificate is delivered or issued for delivery by the issuer. “Restricted network provision” means any provision which conditions the payment of benefits, in whole or in part, on the use of network providers. “Secretary” means the Secretary of the United States Department of Health and Human Services. “Service area” means the geographic area approved by the Secretary of the Maryland Department of Health within which an issuer is authorized to offer a Medicare Select policy. “2010 standardized Medicare supplement benefit plan”, “2010 standardized benefit plan”, or “2010 plan” means a group or individual policy of Medicare supplement insurance issued with an effective date for coverage on or after June 1, 2010. A policy or certificate may not be advertised, solicited, or issued for delivery in this State as a Medicare supplement policy or certificate unless the policy or certificate contains definitions or terms which conform to the requirements of these regulations. Policy Terms Defined. Accident. “Accident”, “accidental injury”, or “accidental means” shall be defined to employ “result” language. “Accident”, “accidental injury”, or “accidental means” does not include words which establish an accidental means test or use words such as “external, violent, visible wounds” or similar words of description or characterization. The definition may not be more restrictive than the following: “Injury or injuries for which benefits are provided means accidental bodily injury sustained by the insured person which is the direct result of an accident, independent of disease or bodily infirmity or any other cause, and occurs while insurance coverage is in force.” The definition may provide that injuries not include injuries for which benefits are provided or available under any workers' compensation, employer's liability or similar law, or motor vehicle no-fault plan, unless prohibited by law. “Benefit period” or “Medicare benefit period” may not be defined more restrictively than as defined in the Medicare program. “Convalescent nursing home”, “extended care facility”, or “skilled nursing facility” may not be defined more restrictively than as defined in the Medicare program. “Health care expenses” means, for the purposes of Regulation .11 of this chapter, expenses of health maintenance organizations associated with the delivery of health care services, which expenses are analogous to incurred losses of insurers. “Hospital” may be defined in relation to its status, facilities, and available services or to reflect its accreditation by the Joint Commission on Accreditation of Hospitals, but not more restrictively than as defined in the Medicare program. “Medicare” shall be defined in the policy and certificate. Medicare may be substantially defined as “The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as then constituted or later amended”, or “Title I, Part I of Public Law 89-97, as Enacted by the Eighty-Ninth Congress of the United States and popularly known as the Health Insurance for the Aged Act, as then constituted and any later amendments or substitutes of it” or words of similar import. “Medicare eligible expenses” means expenses of the kinds covered by Medicare Parts A and B, to the extent recognized as reasonable and medically necessary by Medicare. Restrictions on Policy Definitions. “Physician” may not be defined more restrictively than as defined in the Medicare program. Sickness. “Sickness” may not be defined to be more restrictive than the following: Sickness means illness or disease of an insured person which first manifests itself after the effective date of insurance and while the insurance is in force. This definition may be further modified to exclude sicknesses or diseases for which benefits are provided under any workers' compensation, occupational disease, employer's liability, or similar law. An issuer may not deliver or issue for delivery a Medicare supplement policy or certificate to a resident of this State unless the policy form or certificate form has been filed with and approved by the Commissioner in accordance with filing requirements and procedures prescribed by applicable provisions of Insurance Article, §§12-203, 12-205, and 14-126, Annotated Code of Maryland, and other applicable provisions of Insurance Article and Health-General Article, Title 19, Subtitle 7, Annotated Code of Maryland, and applicable regulations and procedures for filing for approval of forms. An issuer shall file any riders or amendments to policy or certificate forms to delete outpatient prescription drug benefits as required by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 only with the commissioner in the state in which the policy or certificate was issued. Premium Rates. An insurer may not use or change premium rates for a Medicare supplement policy or certificate unless the rates, rating schedule, methodology, and supporting documentations have been filed with and approved by the Commissioner in accordance with the filing requirements and procedures prescribed by the Commissioner. An issuer may not increase the premium rates for a Medicare Supplement policy for an insured person until: For an individual policy, at least 1 year after the date on which the individual policy became effective; and For a group policy, at least 1 year after the date on which the certificate became effective. Starting 1 year after the date on which an individual policy or certificate became effective, an issuer may not increase the premium rates for a Medicare Supplement policy for an insured person more than once each year. Filing for Approval. Except as provided in §D(2) of this regulation, an issuer may not file for approval more than one form of a policy or certificate of each type for each standard Medicare supplement benefit plan. An issuer may offer, with the approval of the Commissioner, up to four additional policy forms or certificate forms of the same type for the same standard Medicare supplement benefit plan, one for each of the following cases: The inclusion of new or innovative benefits; The addition of either direct response or agent marketing methods; The addition of either guaranteed issue or underwritten coverage; The offering of coverage to individuals eligible for Medicare by reason of disability. For the purposes of this section, a “type” means an individual policy, a group policy, an individual Medicare Select policy, or a group Medicare Select policy. Availability. Except as provided in §E(2) of this regulation, an issuer shall continue to make available for purchase any policy form or certificate form issued after the effective date of this regulation that has been approved by the Commissioner. A policy form or certificate form may not be considered to be available for purchase unless the issuer has actively offered it for sale in the previous 12 months. An issuer may discontinue the availability of a policy form or certificate form if the issuer provides to the Commissioner in writing its decision at least 30 days before discontinuing the availability of the form of the policy or certificate. After the effective date of the notice, the issuer may no longer offer for sale the policy form or certificate form in this State. An issuer that discontinues the availability of a policy form or certificate form in accordance with §E(2) of this regulation may not file for approval a new policy form or certificate form of the same type for the same standard Medicare supplement benefit plan as the discontinued form for a period of 5 years after the issuer provides notice to the Commissioner of the discontinuance. The period of discontinuance may be reduced if the Commissioner determines that a shorter period is appropriate. The sale or other transfer of Medicare supplement business to another issuer shall be considered a discontinuance for the purposes of this section. A change in the rating structure or methodology shall be considered a discontinuance under this section unless the issuer complies with the following requirements: The issuer provides an actuarial memorandum, in a form and manner prescribed by the Commissioner, describing the manner in which the revised rating methodology and resultant rates differ from the existing rating methodology and existing rates. The issuer does not subsequently put into effect a change of rates or rating factors that would cause the percentage differential between the discontinued and subsequent rates as described in the actuarial memorandum to change. The Commissioner may approve a change to the differential which is in the public interest. Basis of Experience Calculation. Except as provided in §F(2) of this regulation, the experience of all policy forms or certificate forms of the same type in a standard Medicare supplement benefit plan shall be combined for purposes of the refund or credit calculation prescribed in Regulation .11 of this chapter. Forms assumed under an assumption reinsurance agreement may not be combined with the experience of other forms for purposes of the refund or credit calculation. An issuer shall provide a copy of any Medicare supplement advertisement intended for use in this State whether through written, radio, or television medium or otherwise, to the Commissioner for review by the Commissioner at least 5 business days before using the advertisement. Period of Open Enrollment. An issuer may not deny or condition the issuance or effectiveness of any Medicare supplement policy or certificate available for sale in this State, nor discriminate in the pricing of the policy or certificate because of the health status, claims experience, receipt of health care, or medical condition of an applicant when: An application for the policy or certificate is submitted during the 6-month period beginning with the first day of the first month in which an individual is both 65 years old or older and is enrolled for benefits under Medicare Part B; or An application for the policy or certificate is submitted on or up to 30 days after the birthday of an individual enrolled in a Medicare supplement policy or certificate. Each Medicare supplement policy and certificate currently available from an issuer shall be made available to all applicants who qualify under §A(1)(a) of this regulation without regard to age. Subject to Regulation .31A of this chapter, an insurer shall make available to applicants who qualify under §A(1)(b) of this regulation Medicare supplement policies or certificates with benefits that are equal to or less than the benefits of the applicant’s existing Medicare supplement policy or certificate. For the purpose of this regulation, “benefits that are equal to or less than the benefits of the applicant’s existing Medicare supplement policy or certificate” means a policy or certificate of the same or lower benefit level as indicated in the below chart. Application of Creditable Coverage. If an applicant qualifies under §A of this regulation and submits an application during the time period referenced in §A of this regulation and, as of the date of application, has had a continuous period of creditable coverage of at least 6 months, the issuer may not exclude benefits based on a preexisting condition. If the applicant qualifies under §A of this regulation and submits an application during the time period referenced in §A of this regulation and, as of the date of application, has had a continuous period of creditable coverage that is less than 6 months, the issuer shall reduce the period of any preexisting condition exclusion by the aggregate of the period of creditable coverage applicable to the applicant as of the enrollment date. The Secretary shall specify the manner of the reduction under §B(2) of this regulation. Except as provided in §B of this regulation and in Regulations .09-1 and .18 of this chapter, §A of this regulation is not to be construed as preventing the exclusion of benefits under a policy during the first 6 months based on a preexisting condition for which the policyholder or certificate holder received treatment or was otherwise diagnosed during the 6 months before the policy became effective. Individuals Younger than 65 Years Old and Enrolled in Medicare Part B. An issuer shall comply with the open enrollment requirements that are described in Insurance Article, §15-909, Annotated Code of Maryland, as applying to individuals who are both younger than 65 years old and enrolled in Part B of Medicare. Except for permitted preexisting condition clauses as described in Regulations .08B and .27B(2) of this chapter, a policy or certificate may not be advertised, solicited, or issued for delivery in this State as a Medicare supplement policy if the policy or certificate contains limitations or exclusions on coverage that are more restrictive than those of Medicare. A Medicare supplement policy or certificate may not use waivers to exclude, limit, or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions. A Medicare supplement policy or certificate in force in this State may not contain benefits which duplicate benefits provided by Medicare. Polices With Benefits for Outpatient Prescription Drugs. Subject to COMAR 31.10.05.07B(4) and (6)—(9), and Regulation .08B(5)—(10) of this chapter, a Medicare supplement policy with benefits for outpatient prescription drugs in existence before January 1, 2006, shall be renewed for current policyholders who do not enroll in Part D at the option of the policyholder. A Medicare supplement policy with benefits for outpatient prescription drugs may not be issued after December 31, 2005. After December 31, 2005, a Medicare supplement policy with benefits for outpatient prescription drugs may not be renewed after the policyholder enrolls in Medicare Part D unless: The policy is modified to eliminate outpatient prescription coverage for expenses of outpatient prescription drugs incurred after the effective date of the individual's coverage under a Part D plan; and Premiums are adjusted to reflect the elimination of outpatient prescription drug coverage at the time of Medicare Part D enrollment, accounting for any claims paid, if applicable. General Standards. The following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this State on or after July 14, 1992, and with an effective date for coverage before June 1, 2010. A policy or certificate may not 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. Required Standards. The standards in this section apply to Medicare supplement policies and certificates and are in addition to all other requirements of these regulations. A Medicare supplement policy or certificate may not exclude or limit benefits for losses incurred more than 6 months from the effective date of coverage because it involved a preexisting condition. The policy or certificate may not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within 6 months before the effective date of coverage. A Medicare supplement policy or certificate may not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents. 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 these changes. A Medicare supplement policy or certificate may not provide for termination of coverage of a spouse solely because of the occurrence of an event specified for termination of coverage of the insured, other than the nonpayment of premium. Each Medicare supplement policy shall be guaranteed renewable. The issuer may not: Cancel or nonrenew the policy solely on the ground of health status of the individual; or Cancel or nonrenew the policy for any reason other than nonpayment of premium or material misrepresentation. If the Medicare supplement policy is terminated by the group policyholder and is not replaced as provided under §B(9) of this regulation, the issuer shall offer certificate holders an individual Medicare supplement policy which at the option of the certificate holder provides for: Continuation of the benefits contained in the group policy; or Benefits which meet the requirements of these regulations. If an individual is a certificate holder in a group Medicare supplement policy and the individual terminates membership in the group, the issuer shall: Offer the certificate holder the conversion option described in §B(7) of this regulation; or At the option of the group policyholder, offer the certificate holder continuation of coverage under the group policy. If a group Medicare supplement policy is replaced by another group Medicare supplement policy purchased by the same policyholder, the succeeding issuer shall offer coverage to all persons covered under the old group policy on the group policy's date of termination. Coverage under the new policy may not result in any exclusion for preexisting conditions that would have been covered under the group policy being replaced. 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 §B(6) of this regulation. Extension of Benefits. Termination of a Medicare supplement policy or certificate shall be without prejudice to any continuous loss that 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 may not be considered in determining a continuous loss under §B(11)(a) of this regulation. Suspension of Benefits. 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 a period not to exceed 24 months in which the policyholder or certificate holder has applied for and is determined to be entitled to medical assistance under Title XIX of the Social Security Act (Medicaid), but only if the policyholder or certificate holder notifies the issuer of the policy or certificate within 90 days after the date the individual becomes entitled to medical assistance. If the suspension described in §B(12)(a) of this regulation occurs and if the policyholder or certificate holder loses entitlement to Medicaid, the policy or certificate shall be automatically reinstituted, effective as of the date of termination of entitlement, if the policyholder or certificate holder provides notice of loss of entitlement within 90 days after the date of loss of entitlement and pays the premium attributable to the period, effective as of the date of termination of entitlement. A 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 §226(b) of the Social Security Act; and Covered under a group health plan as defined in §1862(b)(1)(A)(v) of the Social Security Act. If the suspension described in §B(12)(c) of this regulation occurs and if the policyholder or the certificate holder loses coverage under the group health plan, the Medicare supplement policy shall be reinstituted automatically, effective as of the date of the loss of coverage under the group health plan, if the policyholder described in §B(12)(c): Provides notice of loss of coverage within 90 days after the date of the loss of group coverage; and Pays the premium attributable to the period, effective as of the date of termination of enrollment in the group health plan. Reinstitution of coverage under §B(12)(b) or (d) of this regulation: May not provide for any waiting period with respect to treatment of preexisting conditions; Shall provide for resumption of coverage that is substantially equivalent to coverage in effect before the date of suspension; If the suspended Medicare supplement policy provided coverage for outpatient prescription drugs, shall provide for the reinstitution of the policy for Medicare Part D enrollees without coverage for outpatient prescription drugs and shall otherwise provide substantially equivalent coverage to the coverage in effect before the date of suspension; and 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. Exchange Offer. If an issuer makes a written offer to each Medicare supplement policyholder or certificate holder of one or more of its plans, to exchange during a specified period the individual's 1990 standardized benefit plan, as described in Regulation .09 of this chapter, for a 2010 standardized benefit plan, as described in Regulation .28 of this chapter, the offer and subsequent exchange shall comply with the requirements of this subsection. An issuer need not provide justification to the Commissioner if the insured replaces a 1990 standardized benefit plan policy or certificate with an issue age rated 2010 standardized plan policy or certificate at the insured's original issue age and duration. If an insured's policy or certificate to be replaced is priced on an issue age rate schedule at the time of the offer, the rate charged to the insured for the new exchanged policy shall recognize the policy reserve buildup, due to the prefunding inherent in the use of an issue age rate basis, for the benefit of the insured. The rate method proposed to be used by an issuer shall be filed with the Commissioner in accordance with COMAR 31.10.01.02. The rating class of the new policy or certificate shall be the class closest to the insured's class of the replaced coverage. An issuer may not apply a new preexisting condition limitation or a new incontestability period to the new policy for those benefits contained in the exchanged 1990 standardized benefit plan policy or certificate of the insured, but may apply a preexisting condition limitation of not more than 6 months to any added benefits contained in the new 2010 standardized benefit plan policy or certificate not contained in the exchanged policy. The new policy or certificate shall be offered to each policyholder or certificate holder within a given plan, except where the offer or issue would be in violation of State or federal law. Standards for Basic (Core) Benefits Common to Benefit Plans A—J. Every issuer shall make available a policy or certificate including only the following basic core package of benefits to each prospective insured: Coverage of Part A Medicare eligible expenses for hospitalization to the extent not covered by Medicare from the 61st day through the 90th day in any Medicare benefit period; 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; Upon exhaustion of the Medicare hospital inpatient coverage including the lifetime reserve days, coverage of 100 percent 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; 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; 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. The provider shall accept the issuer's payment of the Medicare Part A eligible expenses for hospitalization under §C(1)(c) of this regulation as payment in full and may not bill the insured for any balance. 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 instead of the core package. Standards for Additional Benefits. The following additional benefits shall be included in Medicare supplement benefit plans B through J only as provided by Regulation .09 of this chapter: Medicare Part A Deductible. Coverage for all of the Medicare Part A inpatient hospital deductible amount per benefit period. Skilled Nursing Facility Care. Coverage for the actual billed charges up to the coinsurance amount 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. Medicare Part B Deductible. Coverage for all of the Medicare Part B deductible amount per calendar year regardless of hospital confinement. Eighty percent of the Medicare Part B Excess Charges. Coverage for 80 percent 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. One hundred percent 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. Basic Outpatient Prescription Drug Benefit. Coverage for 50 percent 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. Extended Outpatient Prescription Drug Benefit. Coverage for 50 percent 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. Medically Necessary Emergency Care in a Foreign Country. Coverage to the extent not covered by Medicare for 80 percent 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 60 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” means care needed immediately because of an injury or an illness of sudden and unexpected onset. Preventive Medical Care Benefit. Coverage for the following preventive health services not covered by Medicare: An annual clinical preventive medical history and physical examination that may include tests and services from §D(9)(a)(ii) of this regulation and patient education to address preventive health care measures; and 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 percent 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 (AMA CPT) Codes, to a maximum of $120 annually under this benefit, and this benefit may not include payment for any procedure covered by Medicare. At-Home Recovery Benefit. Coverage for services to provide short-term, at-home assistance with activities of daily living for those recovering from an illness, injury, or surgery. For purposes of the at-home recovery 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/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 this place qualifies as a residence for home health care services covered by Medicare. A hospital or skilled nursing facility may 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 4 hours in a 24-hour period of services provided by a care provider is one visit. Coverage Requirements and Limitations. At-home recovery services provided shall be primarily services which assist in activities of daily living. The insured's attending physician shall 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 was approved by Medicare. Limitation of Coverage. Coverage is limited to: 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 may not exceed the number of Medicare-approved home health care visits under a Medicare-approved home care plan of treatment. The actual charges for each visit up to a maximum reimbursement of $40 per visit. $1,600 per calendar year. Seven visits in any 1 week. Care furnished on a visiting basis in the insured's home. Services provided by a care provider as defined in §D(10)(b)(ii) of this regulation. At-home recovery visits while the insured is covered under the policy or certificate and not otherwise excluded. At-home recovery visits received during the period the insured is receiving Medicare-approved home care services or not more than 8 weeks after the service date of the last Medicare-approved home health care visit. Coverage is excluded for: Home care visits paid for by Medicare or other government programs; Care provided by family members, unpaid volunteers, or providers who are not care providers. Standards for Plans K and L. Standardized Medicare supplement benefit plan K shall consist of the following: Coverage of 100 percent of the Part A hospital coinsurance amount for each day used from the 61st through the 90th day in any Medicare benefit period; Coverage of 100 percent 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; Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 100 percent 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; Medicare Part A deductible: Coverage for 50 percent of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in §E(1)(j) of this regulation; Skilled nursing facility care: Coverage for 50 percent 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 §E(1)(j) of this regulation; Hospice care: Coverage for 50 percent of cost sharing for all Part A Medicare eligible expenses and respite care until the out-of-pocket limitation is met as described in §E(1)(j) of this regulation; Coverage for 50 percent, under Medicare Part A or B, of the reasonable cost of the first 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 §E(1)(j) of this regulation; Except for coverage provided in §E(1)(i) of this regulation, coverage for 50 percent 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 §E(1)(j) of this regulation; Coverage of 100 percent of the cost sharing for Medicare Part B preventive services after the policyholder pays the Part B deductible; and Coverage of 100 percent 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. The provider shall accept the issuer's payment of the Medicare Part A eligible expenses for hospitalization under §E(1)(c) of this regulation as payment in full and may not bill the insured for any balance. Standardized Medicare supplement benefit plan L shall consist of the following: The benefits described in §E(1)(a)—(c) and(i) of this regulation; The benefits described in §E(1)(d)—(h) of this regulation, but substituting 75 percent for 50 percent; and The benefit described in §E(1)(j) of this regulation, but substituting $2,000 for $4,000. Definitions. In this regulation, the following term has the meaning indicated. Term Defined. “Structure, language, and format” means style, arrangement, and overall content of a benefit. General Standards. The standards found in §§C—I of this regulation are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this State on or after July 14, 1992, and with an effective date for coverage before June 1, 2010. A policy or certificate may not be advertised, solicited, delivered, or issued for delivery in this State as a Medicare supplement policy or certificate during the time period described in §B(1) of this regulation unless it complies with the benefit plan standards described in this regulation. An issuer shall make available to each prospective policyholder and certificate holder a policy form or certificate form containing only the core benefits, as defined in Regulation .08C of this chapter. Groups, packages, or combinations of Medicare supplement benefits other than those listed in this regulation may not be offered for sale in this State, except as may be permitted in §I of this regulation and Regulation .24 of this chapter. Structure of Benefits. Benefit plans shall be uniform in structure, language, designation, and format to the standard benefit plans A through L listed in this regulation and conform to the definitions in Regulations .02 and .03 of this chapter. Each benefit shall be structured in accordance with the format provided in Regulation .08C—E of this chapter and list the benefits in the order shown in this regulation. An issuer may use, in addition to the benefit plan designations required in §E of this regulation, other designations to the extent permitted by law. Make-up of 1990 Standardized Benefit Plans. Standardized Medicare supplement benefit plan A shall be limited to the basic (core) benefits common to all benefit plans, as defined in Regulation .08C of this chapter. Standardized Medicare supplement benefit plan B shall include only the following: The core benefit as defined in Regulation .08C of this chapter, plus the Medicare Part A Deductible as defined in Regulation .08D(1) of this chapter. Standardized Medicare supplement benefit plan C shall include only the following: The core benefit as defined in Regulation .08C of this chapter, 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 Regulation .08D(1), (2), (3), and (8) of this chapter. Standardized Medicare supplement benefit plan D shall include only the following: The core benefit, as defined in Regulation .08C of this chapter, plus the Medicare Part A Deductible, Skilled Nursing Facility Care, Medically Necessary Emergency Care in a Foreign Country, and the At-Home Recovery Benefit as defined in Regulation .08D(1), (2), (8), and (10) of this chapter. Standardized Medicare supplement benefit plan E shall include only the following: The core benefit as defined in Regulation .08C of this chapter, 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 Regulation .08D(1), (2), (8), and (9) of this chapter. Standardized Medicare supplement benefit plan F shall include only the following: The core benefit as defined in Regulation .08C of this chapter, plus the Medicare Part A Deductible, the Skilled Nursing Facility Care, the Part B Deductible, 100 Percent of the Medicare Part B Excess Charges, and Medically Necessary Emergency Care in a Foreign Country as defined in Regulation .08D(1), (2), (3), (5), and (8) of this chapter. High Deductible Plan F. Standardized Medicare supplement benefit high deductible plan F shall include only 100 percent of covered expenses following the payment of the annual high deductible plan F deductible. The covered expenses include the core benefit as defined in Regulation .08C of this chapter, plus the Medicare Part A Deductible, Skilled Nursing Facility Care, the Medicare Part B Deductible, 100 Percent of the Medicare Part B Excess Charges, and Medically Necessary Emergency Care in a Foreign Country as defined in Regulation .08D(1)—(3), (5), and (8) of this chapter. The annual high deductible plan F deductible shall consist of out-of-pocket expenses, other than premiums, for services covered by the Medicare supplement plan F policy, and is in addition to any other specific benefit deductibles. The annual high deductible plan F deductible is $1,500 for 1999, and is based on the calendar year. The deductible shall be adjusted annually after 1999 by the Secretary to reflect the change in the Consumer Price Index for all urban consumers for the 12-month period ending with August of the preceding year, and rounded to the nearest multiple of $10. Standardized Medicare supplement benefit plan G shall include only the following: The core benefit as defined in Regulation .08C of this chapter, plus the Medicare Part A Deductible, Skilled Nursing Facility Care, 80 Percent of the Medicare Part B Excess Charges, Medically Necessary Emergency Care in a Foreign Country, and the At-Home Recovery Benefit as defined in Regulation .08D(1), (2), (4), (8), and (10) of this chapter. Standardized Medicare Supplement Benefit Plan H. Standardized Medicare supplement benefit plan H shall consist of only the following: The core benefit as defined in Regulation .08C of this chapter, 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 Regulation .08D(1), (2), (6), and (8) of this chapter. The outpatient prescription drug benefit may not be included in a Medicare supplement policy sold after December 31, 2005. Standardized Medicare Supplement Benefit Plan I. Standardized Medicare supplement benefit plan I shall consist of only the following: The core benefit as defined in Regulation .08C of this chapter, plus the Medicare Part A Deductible, Skilled Nursing Facility Care, 100 Percent 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 Regulation .08D(1), (2), (5), (6), (8), and (10) of this chapter. The outpatient prescription drug benefit may not be included in a Medicare supplement policy sold after December 31, 2005. Standardized Medicare Supplement Benefit Plan J. Standardized Medicare supplement benefit plan J shall consist of only the following: The core benefit as defined in Regulation .08C of this chapter, plus the Medicare Part A Deductible, Skilled Nursing Facility Care, Medicare Part B Deductible, 100 Percent 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 Regulation .08D(1)—(3) and (5)—(10) of this chapter. The outpatient prescription drug benefit may not be included in a Medicare supplement policy sold after December 31, 2005. High Deductible Plan J. Standardized Medicare supplement benefit high deductible plan J shall consist of only 100 percent of covered expenses following the payment of the annual high deductible plan J deductible. The covered expenses include the core benefit as defined in Regulation .08C of this chapter, plus the Medicare Part A deductible, skilled nursing facility care, Medicare Part B deductible, 100 percent 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 Regulation .08D(1)—(3), (5), and (7)—(10) of this chapter. 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 is in addition to any other specific benefit deductibles. The annual deductible is $1,500 for 1999 and is based on a calendar year. The deductible shall be adjusted annually after 1999 by the Secretary to reflect the change in the Consumer Price Index for all urban consumers for the 12-month period ending with August of the preceding year, and rounded to the nearest multiple of $10. The outpatient prescription drug benefit may not be included in a Medicare supplement policy sold after December 31, 2005. Plans Mandated by the Medicare Prescription Drug, Improvement and Modernization Act of 2003. Standardized Medicare supplement benefit plan K shall consist of only those benefits described in Regulation .08E(1) of this chapter. Standardized Medicare supplement benefit plan L shall consist of only those benefits described in Regulation .08E(3) of this chapter. 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 benefits provided in a policy or certificate that otherwise complies with the applicable standards. The new or innovative benefits described in §I(1) of this regulation may include benefits that are appropriate to Medicare supplement insurance, new or innovative, not otherwise available, cost-effective, and offered in a manner that is consistent with the goal of simplification of Medicare supplement policies. After December 31, 2005, the innovative benefit may not include an outpatient prescription drug benefit. Guaranteed Issue. Eligible individuals are those individuals described in §B of this regulation who: Seek to enroll under the policy during the period specified in §C of this regulation; and Submit evidence of the date of termination, disenrollment, or Medicare Part D enrollment with the application for a Medicare supplement policy. With respect to eligible individuals, an issuer may not: Deny or condition the issuance or effectiveness of a Medicare supplement policy described in §E of this regulation that is offered and is available for issuance to new enrollees by the issuer; Discriminate in the pricing of a Medicare supplement policy described in §E of this regulation because of health status, claims experience, receipt of health care, or medical condition; and Impose an exclusion of benefits based on a preexisting condition under a Medicare supplement policy described in §E of this regulation. An eligible individual is an individual described in any of the following: The individual is enrolled under an employee welfare benefit plan that provides health benefits that supplement the benefits under Medicare, and the plan terminates or the plan ceases to provide all supplemental health benefits to the individual; The individual is enrolled with a Medicare Advantage organization under a Medicare Advantage plan under Part C of Medicare, and any of the following circumstances apply: The certification of the organization or plan under the federal Social Security Act has been terminated; The organization has terminated or otherwise discontinued providing the plan in the area in which the individual resides; The individual is no longer eligible to elect the plan because: Of a change in the individual's place of residence, Of another change in circumstances specified by the Secretary, but not including termination of the individual's enrollment on the basis described in §1851(g)(3)(B) of the federal Social Security Act (when the individual has not paid premiums on a timely basis or has engaged in disruptive behavior as specified in standards under §1856 of the federal Social Security Act), or The plan is terminated for all individuals within a residence area; The individual demonstrates, in accordance with guidelines established by the Secretary, that: The organization offering the plan substantially violated a material provision of the organization's contract under Part C of Medicare in relation to the individual, including the failure to provide an enrollee on a timely basis medically necessary care for which benefits are available under the plan or the failure to provide medically necessary covered care in accordance with applicable quality standards, or The organization, or agent or other entity acting on the organization's behalf, materially misrepresented the plan's provisions in marketing the plan to the individual; or The individual meets any other exceptional conditions as the Secretary may provide; The individual is 65 years old or older and is enrolled with a Program of All-Inclusive Care for the Elderly (PACE) provider under §1894 of the Social Security Act, and there are circumstances similar to those described in §B(2) of this regulation that would permit discontinuance of the individual's enrollment with the PACE provider if the individual were enrolled in a Medicare Advantage plan; The individual: Is enrolled with: An eligible organization under a contract under §1876 of the federal Social Security Act (Medicare cost), A similar organization to the organization described in §B(4)(a)(i) of this regulation operating under demonstration project authority, effective for periods before April 1, 1999, An organization under an agreement under §1833(a)(1)(A) of the federal Social Security Act (health care prepayment plan), or An organization under a Medicare Select policy; and Ceases to be enrolled under the same circumstances that would permit discontinuance of an individual's election of coverage under §B(2) of this regulation; The individual is enrolled under a Medicare supplement policy and the enrollment ceases because of: The insolvency of the issuer or bankruptcy of the nonissuer organization or other involuntary termination of coverage or enrollment under the policy; The issuer of the policy substantially violated a material provision of the policy; or The issuer, or an agent or other entity acting on the issuer's behalf, materially misrepresented the policy's provisions in marketing the policy to the individual; The individual: Was enrolled under a Medicare supplement policy and terminates enrollment and subsequently enrolls, for the first time with: Any Medicare Advantage organization under a Medicare Advantage plan under Part C of Medicare, Any eligible organization under a contract under §1876 of the federal Social Security Act (Medicare cost), Any similar organization operating under demonstration project authority, A Medicare Select policy, or Any Program of All-Inclusive Care for the Elderly (PACE) provider under §1894 of the Social Security Act; and Terminates the subsequent enrollment under §B(6)(a) of this regulation during any period within the first 12 months of the subsequent enrollment (during which the enrollee is permitted to terminate the subsequent enrollment under §1851(e) of the federal Social Security Act); The individual, upon first becoming enrolled in Part B of Medicare at 65 years old or older, enrolls in a Medicare Advantage plan under Part C of Medicare, or with a PACE provider under §1894 of the Social Security Act, and disenrolls from the plan or program by not later than 12 months after the effective date of enrollment; or The individual: Enrolls in a Medicare Part D plan during the initial enrollment period; At the time of enrollment in Part D: Was enrolled under a Medicare supplement policy that covers outpatient prescription drugs; and Terminates enrollment in the Medicare supplement policy described in §B(8)(b)(i) of this regulation; and Submits evidence of enrollment in Medicare Part D with the application for a policy described in §E(5) of this regulation. Guaranteed Issue Time Periods. The guaranteed issue period for an individual described in §B(1) of this regulation: Begins on the later of the date: The individual receives a notice of termination or cessation of all supplemental health benefits, or, if the individual does not receive the notice, the date the individual receives notice that a claim has been denied because of a termination or cessation of all supplemental health benefits; or The applicable coverage terminates or ceases; and Ends 63 days after the beginning of the period described in §C(1)(a) of this regulation. The guaranteed issue period for an individual described in §B(2)—(4), (6), or (7) of this regulation whose enrollment is terminated involuntarily: Begins on the date that the individual receives a notice of termination; and Ends 63 days after the date the applicable coverage is terminated. The guaranteed issue period for an individual described in §B(5)(a) of this regulation: Begins on the earlier of: The date that the individual receives a notice of termination, a notice of the issuer's bankruptcy or insolvency, or other similar notice, if any; or The date that the applicable coverage is terminated; and Ends on the date that is 63 days after the date the coverage is terminated. The guaranteed issue period for an individual described in §B(2), (3), (5)(b), (5)(c), (6), or (7) of this regulation, who disenrolls voluntarily: Begins on the date that is 60 days before the effective date of the disenrollment; and Ends on the date that is 63 days after the effective date. The guaranteed issue period for an individual described in §B(8) of this regulation: Begins on the date the individual receives notice pursuant to §1882(v)(2)(B) of the Social Security Act from the Medicare supplement issuer during the 60-day period immediately preceding the initial Part D enrollment period; and Ends on the date that is 63 days after the effective date of the individual's coverage under Medicare Part D. The guaranteed issue period for an individual described in §B of this regulation but not described in §C(1)—(5) of this regulation: Begins on the effective date of disenrollment; and Ends on the date that is 63 days after the effective date of disenrollment. Extended Medigap Access for Interrupted Trial Periods. A subsequent enrollment of an individual described in §B(6) of this regulation shall be deemed to be a first time enrollment described in §B(6) of this regulation if both of the following are satisfied: The individual's enrollment with an organization or provider described in §B(6)(a) of this regulation is involuntarily terminated within the first 12 months of enrollment; and The individual enrolls with another organization or provider described in §B(6)(a) of this regulation without an intervening enrollment. A subsequent enrollment of an individual described in §B(7) of this regulation shall be deemed to be a first time enrollment described in §B(7) of this regulation if both of the following are satisfied: The individual's enrollment with a plan or in a program described in §B(7) of this regulation is involuntarily terminated within the first 12 months of enrollment; and The individual enrolls in another plan or program described in §B(7) of this regulation, without an intervening enrollment. For purposes of §B(6) and (7) of this regulation, an enrollment of an individual with an organization or provider described in §B(6)(a) of this regulation, or with a plan or in a program described in §B(7) of this regulation, may not be deemed to be a first time enrollment under this section after the 2-year period beginning on the date on which the individual first enrolled with the organization, provider, plan, or program. Products to Which Eligible Individuals Are Entitled. The Medicare supplement policy to which eligible individuals are entitled under: §B(1)—(5) of this regulation is a Medicare supplement policy which has a benefit package classified as plan A, B, C, F, including F with a high deductible, K, or L offered by any issuer; Subject to §E(3) of this regulation, §B(6) of this regulation is the same Medicare supplement policy in which the individual was most recently previously enrolled, if available from the same issuer, or, if not so available, a policy described in §E(1) of this regulation; §B(6) of this regulation after December 31, 2005, if the individual was most recently enrolled in a Medicare supplement policy with an outpatient prescription drug benefit, a Medicare supplement policy described in this subsection is: The policy available from the same issuer but modified to remove outpatient prescription drug coverage; or At the election of the policyholder, an A, B, C, F, including F with a high deductible, K, or L policy that is offered by any issuer; §B(7) of this regulation shall include any Medicare supplement policy offered by any issuer; and §B(8) of this regulation is a Medicare supplement policy that has a benefit package classified as Plan A, B, C, F, including F with a high deductible, K, or L, and that is offered and is available for issuance to new enrollees by the same issuer that issued the individual's Medicare supplement policy with outpatient prescription drug coverage. Notification Provisions. At the time of an event described in §B of this regulation because of which an individual loses coverage or benefits due to the termination of a contract or agreement, policy, or plan, the organization that terminates the contract or agreement, the issuer terminating the policy, or the administrator of the plan being terminated, respectively, shall notify the individual of the individual's rights under this section, and of the obligations of issuers of Medicare supplement policies under §A of this regulation. The notice required by §F(1) of this regulation shall be communicated contemporaneously with the notification of termination. At the time of an event described in §B of this regulation because of which an individual ceases enrollment under a contract or agreement, policy, or plan, the organization that offers the contract or agreement, regardless of the basis for the cessation of enrollment, the issuer offering the policy, or the administrator of the plan, respectively, shall notify the individual of the individual's rights under this section, and of the obligations of issuers of Medicare supplement policies under §A of this regulation. The notice required by §F(3) of this regulation shall be communicated within 10 working days of the issuer receiving notification of disenrollment. An issuer shall comply with §1882(c)(3) of the Social Security Act, as enacted by §4081(b)(2)(C) of the Omnibus Budget Reconciliation Act of 1987 (OBRA) 1987, Public Law No. 100-203, by: Accepting a notice from a Medicare carrier on dually assigned claims submitted by participating physicians and suppliers as a claim for benefits in place of any other claim form otherwise required and making a payment determination on the basis of the information contained in that notice; Notifying the participating physician or supplier and the beneficiary of the payment determination; Paying the participating physician or supplier directly; Furnishing, at the time of enrollment, each enrollee with a card listing the policy name, number, and a central mailing address to which notices from a Medicare carrier may be sent; Paying user fees for claim notices that are transmitted electronically or otherwise; and Providing to the federal Secretary of Health and Human Services, at least annually, a central mailing address to which all claims may be sent by Medicare carriers. The issuer shall certify to compliance with requirements set forth in §A of this regulation on the Medicare supplement insurance experience reporting form. Loss Ratio Standards. An issuer may not deliver or issue for delivery a Medicare supplement policy form or certificate in this State unless the policy form or certificate can be expected, as estimated for the entire period for which rates are computed to provide coverage, to return to policyholders and certificate holders in the form of aggregate benefits, not including anticipated refunds or credits, provided under the policy form or certificate form: At least 75 percent of the aggregate amount of premiums earned in the case of group policies; or At least 65 percent of the aggregate amount of premiums earned in the case of individual policies. The aggregate benefits as determined in accordance with §A(1)(a) and (b) of this regulation shall be calculated on the basis of incurred claims experience, or incurred health care expenses when coverage is provided by a health maintenance organization on a service rather than reimbursement basis. Earned premiums for the period for which rates are computed shall be calculated in accordance with accepted actuarial principles and practices. Incurred health care expenses where coverage is provided by a health maintenance organization may not include: Home office and overhead costs; Advertising costs; Commissions and other acquisition costs; Taxes; Capital costs; Administrative costs; or Claims processing costs. All filings of rates and rating schedules shall demonstrate that expected claims in relation to premiums comply with the requirements of this regulation when combined with actual experience to date. Filings of rate revisions shall also demonstrate that the anticipated loss ratio over the entire future period for which the revised rates are computed to provide coverage can be expected to meet the appropriate loss ratio standards. For purposes of applying §A(1) of this regulation and Regulation .04C(3) of this chapter only, policies issued as a result of solicitations of individuals through the mails or by mass media advertising, including both print and broadcast advertising, shall be considered to be individual policies. For policies issued before July 1, 1992, expected claims in relation to premiums shall meet the: Originally filed anticipated loss ratio when combined with the actual experience since inception; Appropriate loss ratio requirement from §A(1)(a) and (b) of this regulation when combined with actual experience beginning with April 1, 1996, Appropriate loss ratio requirement from §A(1)(a) and (b) of this regulation over the entire future period for which the rates are computed to provide coverage. Refund or Credit Calculation. An issuer shall collect and file with the Commissioner by May 31 of each year the data contained in the reporting form in Regulation .19 of this chapter for each type of standard Medicare supplement benefit plan. If, on the basis of the experience as reported, the benchmark ratio since inception (ratio 1) exceeds the adjusted experience ratio since inception (ratio 3), then a refund or credit calculation is required. The refund calculation shall be done on a Statewide basis for each type in a standard Medicare supplement benefit plan. For purposes of the refund or credit calculation, experience on policies issued within the reporting year shall be excluded. For purposes of this section, for policies or certificates issued before July 1, 1992, the issuer shall make the refund or credit calculation separately for all individual policies, including all group policies subject to an individual loss ratio standard when issued, combined and all other group policies combined for experience after April 1, 1996. The first report shall be due by May 31, 1998. A refund or credit shall be made only when the benchmark loss ratio exceeds the adjusted experience loss ratio and the amount to be refunded or credited exceeds a de minimis level. The refund shall include interest from the end of the calendar year to the date of the refund or credit at a rate specified by the federal Secretary of Health and Human Services, but may not be less than the average rate of interest for 13-week Treasury notes. A refund or credit against premiums due shall be made by September 30 following the experience year upon which the refund or credit is based. Annual Filing of Premium Rates. An issuer of Medicare supplement policies and certificates issued before or after the effective date of these regulations in this State shall file annually its rates, rating schedule, and supporting documentation including ratios of incurred losses to earned premiums by policy duration for approval by the Commissioner in accordance with the filing requirements and procedures required by the Commissioner. The supporting documentation shall also demonstrate in accordance with actuarial standards of practice, using reasonable assumptions, that the appropriate loss ratio standards can be expected to be met over the entire period for which rates are computed. The demonstration shall exclude active life reserves. An expected third year loss ratio which is greater than or equal to the applicable percentage shall be demonstrated for policies or certificates in force less than 3 years. As soon as practicable, but before the effective date of enhancements in Medicare benefits, every issuer of Medicare supplement policies or certificates in this State shall file with the Commissioner in accordance with the applicable filing procedures of this State: Appropriate premium adjustments necessary to produce loss ratios as anticipated for the current premium for the applicable policies or certificates; and Supporting documents as necessary to justify the adjustment which shall accompany the filing. An issuer shall make the premium adjustments which are necessary to produce an expected loss ratio under the policy or certificate to conform with minimum loss ratio standards for Medicare supplement policies in compliance with §A(1)(a) and (b) of this regulation and which are expected to result in a loss ratio at least as great as that originally anticipated in the rates used to produce current premiums by the issuer for the Medicare supplement policies or certificates. A premium adjustment which would modify the loss ratio experience under the policy other than the adjustments described in §C(3) of this regulation may not be made with respect to a policy at any time other than upon its renewal date or anniversary date. If an issuer fails to make premium adjustments acceptable to the Commissioner, the Commissioner may order premium adjustments, refunds, or premium credits considered necessary to achieve the loss ratio required by this regulation. Before the effective date of changes in Medicare benefits, every issuer of Medicare supplement policies or certificates in this State shall file with the Commissioner for approval appropriate riders, endorsements, or policy forms needed to accomplish the Medicare supplement policy or certificate modifications necessary to eliminate benefit duplications with Medicare. The riders, endorsements, or policy forms shall provide a clear description of the Medicare supplement benefits provided by the policy or certificate. Public Hearings. The Commissioner may conduct a public hearing to gather information concerning a request by an issuer for an increase in a rate for a policy form or certificate form issued before or after the effective date of these regulations if the experience of the form for the previous reporting period is not in compliance with the applicable loss ratio standard. The determination of compliance is made without consideration of any refund or credit for the reporting period. Public notice of the hearing shall be furnished in a manner considered appropriate by the Commissioner. An issuer or other entity may provide commission or other compensation to an agent or other representative for the sale of a Medicare supplement policy or certificate only if the first year commission or other first year compensation is not more than 200 percent of the commission or other compensation paid for selling or servicing the policy or certificate in the second year or period. The commission or other compensation provided in subsequent renewal years shall be the same as that provided in the second year or period and shall be provided for not fewer than 5 renewal years. If an existing Medicare supplement policy or certificate is replaced, an issuer or other entity may not provide compensation to its agents or other producers and an agent or producer may not receive compensation greater than the renewal compensation payable by the replacing issuer on renewal policies or certificates. For purposes of this regulation, “compensation” includes pecuniary or nonpecuniary remuneration of any kind relating to the sale or renewal of the policy or certificate including bonuses, gifts, prizes, awards, and finders fees. Definitions. In this regulation, the following terms have the meanings indicated. Terms Defined. “Form” means the language, format, type size, type proportional spacing, bold character, and line spacing. “Guide” means the Guide to Health Insurance for People with Medicare. General Rules. Medicare supplement policies and certificates shall include a renewal or continuation provision. The language or specifications of this provision shall be consistent with the type of contract issued. The provision shall be appropriately captioned and shall appear on the first page of the policy, and shall include any reservation by the issuer of the right to change premiums and any automatic renewal premium increases based on the policyholder's age. Except for riders or endorsements by which the issuer effectuates a request made in writing by the insured, exercises a specifically reserved right under a Medicare supplement policy, or is required to reduce or eliminate benefits to avoid duplication of Medicare benefits, all riders or endorsements added to a Medicare supplement policy after the date of issue or at reinstatement or renewal which reduce or eliminate benefits or coverage in the policy shall require a signed acceptance by the insured. After the date of the policy or certificate issue, any rider or endorsement which increases benefits or coverage with a concomitant increase in premium during the policy term shall be agreed to in writing signed by the insured, unless the benefits are required by the minimum standards for Medicare supplement policies, or if the increased benefits or coverage are required by law. When a separate additional premium is charged for benefits provided in connection with riders or endorsements, the premium charge shall be set forth in the policy. Medicare supplement policies or certificates may not provide for the payment of benefits based on standards described as “usual and customary”, “reasonable and customary”, or words of similar import. If a Medicare supplement policy or certificate contains any limitations with respect to preexisting conditions, these limitations shall appear as a separate paragraph of the policy and be labeled “preexisting condition limitations”. Medicare supplement policies and certificates shall have a notice prominently printed on the first page of the policy or certificate or attached to it stating in substance that the policyholder or certificate holder shall have the right to return the policy or certificate within 30 days of its delivery and to have the premium refunded if, after examination of the policy or certificate, the insured person is not satisfied for any reason. Guide to Health Insurance for People With Medicare. Issuers of health policies or certificates that provide hospital or medical expense coverage on an expense-incurred or indemnity basis to persons eligible for Medicare shall provide to those applicants a Guide to Health Insurance for People with Medicare in the form developed jointly by the National Association of Insurance Commissioners and the Centers for Medicare and Medicaid Services. The Guide shall be printed in a type size not smaller than 12-point type. Delivery of the Guide shall be made whether or not the policies or certificates are advertised, solicited, or issued as Medicare supplement policies or certificates as defined in this chapter. Except in the case of direct response issuers, issuers shall: Deliver the Guide to the applicant at the time of application; and Obtain acknowledgement of receipt of the Guide. Direct response issuers shall deliver the Guide to the applicant upon request, but not later than at the time the policy is delivered. Notice Requirements. As soon as practicable, but not later than 30 days before the annual effective date of any Medicare benefit changes, an issuer shall notify its Medicare supplement policyholders and certificate holders of modifications the insurer has made to Medicare supplement insurance policies or certificates in a format acceptable to the Commissioner. The notice shall: Include a description of revisions to the Medicare program and a description of each modification made to the coverage provided under the Medicare supplement policy or certificate; and Inform each policyholder or certificate holder as to when any premium adjustment is to be made due to changes in Medicare. The notice of benefit modifications and any premium adjustments shall be in outline form and in clear and simple terms so as to facilitate comprehension. The notice may not contain or be accompanied by a solicitation. MMA Notice Requirements. Issuers shall comply with any notice requirements of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). Outline of Coverage Requirements for Medicare Supplement Policies. Issuers shall provide an outline of coverage to all applicants at the time the application is presented to the prospective applicant and, except for direct response policies, shall obtain an acknowledgement of receipt of the outline from the applicant. If an outline of coverage is provided at the time of application and the Medicare supplement policy or certificate is issued on a basis which would require revision of the outline, the issuer shall provide the applicant with a substitute outline of coverage properly describing the policy or certificate which is delivered. The substitute outline of coverage shall contain the following statement in not less than 12-point type, immediately above the company name: Outline of Coverage. The outline of coverage provided to applicants in accordance with this regulation consists of four parts: A cover page; Premium information; Disclosure pages; and Charts displaying the features of each benefit plan offered by the issuer. The outline of coverage for 2010 standardized Medicare supplement benefit plan policies or certificates shall be in the language and format described in Regulation .30 of this chapter in not less than 12-point type. All plans shall be shown on the cover page, and the plans that are offered by the issuer shall be prominently identified. Premium information for plans that are offered shall be shown on the cover page or immediately following the cover page and shall be prominently displayed. The premium and mode shall be stated for all plans that are offered to the prospective applicant. All possible premiums for the prospective applicant shall be illustrated. “NOTICE: Read this outline of coverage carefully. It is not identical to the outline of coverage provided upon application and the coverage originally applied for has not been issued.” Notice Regarding Policies or Certificates Which Are Not Medicare Supplement Policies. Any health insurance policy or certificate, other than a Medicare supplement policy, or a policy issued pursuant to a contract under §1876 of the federal Social Security Act (42 U.S.C. §1395 et seq.), disability income policy, or other policy identified in Regulation .01C of this chapter, issued for delivery in this State to persons eligible for Medicare shall contain a notice to insureds under the policy that the policy is not a Medicare supplement policy or certificate. The notice shall either be printed or attached to the first page of the outline of coverage delivered to insureds under the policy, or if no outline of coverage is delivered, to the first page of the policy or certificate delivered to the insureds. The notice shall be in not less than 12-point type and contain the following language. Disclosure Statements. Applications provided to persons eligible for Medicare for the health insurance policies or certificates described in §F(1) of this regulation shall disclose, using the applicable statement in Regulation .22 of this chapter, the extent to which the policy duplicates Medicare. The disclosure statement required by §F(2)(a) of this regulation shall be provided as a part of, or together with, the application for the policy or certificate. Required Questions in Medicare Supplement Applications. Application forms shall include the following questions designed to elicit information as to whether, as of the date of the application, the applicant currently has Medicare supplement, Medicare Advantage, Medicaid coverage, or another health insurance policy or certificate in force or whether a Medicare supplement policy or certificate is intended to replace any other accident and sickness policy or certificate presently in force. A supplementary application or other form to be signed by the applicant and insurance producer containing these questions and statements may be used. You do not need more than one Medicare supplement policy. If you purchase this policy, you may want to evaluate your existing health coverage and decide if you need multiple coverages. You may be eligible for benefits under Medicaid and may not need a Medicare supplement policy. If, after purchasing this policy, you become eligible for Medicaid, the benefits and premiums under your Medicare supplement policy can be suspended, if requested, during your entitlement to benefits under Medicaid for 24 months. You must request this suspension within 90 days of becoming eligible for Medicaid. If you are no longer entitled to Medicaid, your suspended Medicare supplement policy (or, if that is no longer available, a substantially equivalent policy) will be reinstituted if requested within 90 days of losing Medicaid eligibility. If the Medicare supplement policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstituted policy will not have outpatient prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the date of the suspension. If you are eligible for, and have enrolled in a Medicare supplement policy by reason of disability and you later become covered by an employer or union-based group health plan, the benefits and premiums under your Medicare supplement policy can be suspended, if requested, while you are covered under the employer or union-based group health plan. If you suspend your Medicare supplement policy under these circumstances, and later lose your employer or union-based group health plan, your suspended Medicare supplement policy (or, if that is no longer available, a substantially equivalent policy) will be reinstituted if requested within 90 days of losing your employer or union-based group health plan. If the Medicare supplement policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstituted policy will not have outpatient prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the date of the suspension. Counseling services may be available in your state to provide advice concerning your purchase of Medicare supplement insurance and concerning medical assistance through the State Medicaid program, including benefits as a Qualified Medicare Beneficiary (QMB) and a Specified Low-Income Medicare Beneficiary (SLMB). Did you turn age 65 in the last 6 months? Did you enroll in Medicare Part B in the last 6 months? If yes, what is the effective date?_____________ Are you covered for medical assistance through the State Medicaid program? Will Medicaid pay your premiums for this Medicare supplement policy? Do you receive any benefits from Medicaid OTHER THAN payments toward your Medicare Part B premium? If you had coverage from any Medicare plan other than original Medicare within the past 63 days (for example, a Medicare Advantage plan, or a Medicare HMO or PPO), fill in your start and end dates below. If you are still covered under this plan, leave “END” blank. If you are still covered under the Medicare plan, do you intend to replace your current coverage with this new Medicare supplement policy? Was this your first time in this type of Medicare plan? Did you drop a Medicare supplement policy to enroll in the Medicare plan? Do you have another Medicare supplement policy in force? If so, with what company, and what plan do you have {optional for Direct Mailers}? If so, do you intend to replace your current Medicare supplement policy with this policy? Have you had coverage under any other health insurance within the past 63 days? (For example, an employer, union, or individual plan) If so, with what company and what kind of policy? What are your dates of coverage under the other policy? If you lost or are losing other health insurance coverage and received a notice from your prior insurer saying you were eligible for guaranteed issue of a Medicare supplement insurance policy, or that you had certain rights to buy such a policy, you may be guaranteed acceptance in one or more of our Medicare supplement plans. Please include a copy of the notice from your prior insurer with your application. PLEASE ANSWER ALL QUESTIONS. Agents shall list any other health insurance policies they have sold to the applicant. List policies sold which are still in force. List policies sold in the past five (5) years which are no longer in force. In the case of a direct response issuer, a copy of the application or supplemental form, signed by the applicant, and acknowledged by the insurer, shall be returned to the applicant by the insurer upon delivery of the policy. Upon determining that a sale will involve replacement of Medicare supplement coverage, any issuer, other than a direct response issuer, or its agent, shall furnish the applicant, prior to issuance or delivery of the Medicare supplement policy or certificate, a notice regarding replacement of Medicare supplement coverage. One copy of the notice signed by the applicant and the agent, except where the coverage is sold without an agent, shall be provided to the applicant and an additional signed copy shall be retained by the issuer. A direct response issuer shall deliver to the applicant at the time of the issuance of the policy the notice regarding replacement of Medicare supplement coverage. The notice required by §D of this regulation for an issuer shall be provided in substantially the following form in not less than 12-point type: Note: If the issuer of the Medicare supplement policy being applied for does not, or is otherwise prohibited from imposing preexisting condition limitations, please skip to statement 2 below. Health conditions which you may presently have (preexisting conditions) may not be immediately or fully covered under the new policy. This could result in denial or delay of a claim for benefits under the new policy, whereas a similar claim might have been payable under your present policy. State law provides your replacement policy or certificate may not contain new preexisting conditions, waiting periods, elimination periods, or probationary periods. The insurer will waive any time periods applicable to preexisting conditions, waiting periods, elimination periods, or probationary periods in the new policy (or coverage) for similar benefits to the extent such time was spent (depleted) under the original policy. If you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical and health history. Failure to include all material medical information on an application may provide a basis for the company to deny any future claims and to refund your premium as though your policy had never been in force. After the application has been completed and before you sign it, review it carefully to be certain that all information has been properly recorded. (If the policy or certificate is guaranteed issue, this paragraph need not appear.) Paragraphs 1 and 2 of the replacement notice (applicable to preexisting conditions) may be deleted by an issuer if the replacement does not involve application of a new preexisting condition limitation. An issuer, directly or through its producers, shall: Establish marketing procedures to assure that any comparison of policies by its agents or other producers will be fair and accurate; Establish marketing procedures to assure that excessive insurance is not sold or issued; Display prominently by type, stamp, or other appropriate means on the first page of the policy the following: “Notice to buyer: This policy may not cover all of your medical expenses.”; Inquire and otherwise make every reasonable effort to identify whether a prospective applicant or enrollee for Medicare supplement insurance already has health insurance and the types and amounts of any insurance; Establish auditable procedures for verifying compliance with this section. In addition to the practices prohibited in Insurance Article, Title 27, Annotated Code of Maryland, the following acts and practices are prohibited: Twisting: Knowingly making any misleading representation or incomplete or fraudulent comparison of any insurance policies or insurers for the purpose of inducing, or tending to induce, any person to lapse, forfeit, surrender, terminate, retain, pledge, assign, borrow on, or convert any insurance policy or to take out a policy of insurance with another insurer; High pressure tactics: Employing any method of marketing having the effect of or tending to induce the purchase of insurance through force, fright, threat, whether explicit or implied, or undue pressure to purchase or recommend the purchase of insurance; Cold lead advertising: Making use directly or indirectly of any method of marketing which fails to disclose in a conspicuous manner that a purpose of the method of marketing is solicitation of insurance and that contact will be made by an insurance agent or insurance company. The terms “Medicare Supplement”, “Medigap”, “Medicare Wrap-Around”, and words of similar import may not be used unless the policy is issued in compliance with these regulations. In recommending the purchase or replacement of any Medicare supplement policy or certificate an agent shall make reasonable efforts to determine the appropriateness of a recommended purchase or replacement. Any sale of a Medicare supplement policy or certificate that will provide an individual more than one Medicare supplement policy or certificate is prohibited. An issuer may not issue a Medicare supplement policy or certificate to an individual enrolled in Medicare Part C unless the effective date of the coverage is after the termination date of the individual's Part C coverage. On or before March 1 of each year, an issuer shall report the following information for every individual resident of this State for which the issuer has in force more than one Medicare supplement policy or certificate: Policy or certificate number; and Date of issuance. The items set forth in §A of this regulation shall be grouped by individual policyholder. If a Medicare supplement policy or certificate replaces another Medicare supplement policy or certificate, the replacing issuer shall waive any time periods applicable to preexisting conditions, waiting periods, elimination periods, and probationary periods in the new Medicare supplement policy or certificate to the extent time was spent under the original policy. If a Medicare supplement policy or certificate replaces another Medicare supplement policy or certificate which has been in effect for at least 6 months, the replacing policy may not provide any time period applicable to preexisting conditions, waiting periods, elimination periods, and probationary periods. The following forms are to be used for reporting loss ratios and calculating refunds for credits required under Regulation .11B of this chapter: Medicare Supplement Refund Calculation Form. Signature ________________________________ Name-Please Type ________________________________ Title-Please Type ________________________________ Date Reporting Form for Benchmark Ratio for Group Policies. Reporting Form for Benchmark Ratio for Individual Policies. The following form is to be used in making reports of multiple policies in accordance with the requirements of Regulation .17 of this chapter: (a)3 (b)4 (c) (d) (e) (f) (g) (h) (i) (j) (o)5 Year Earned Premium Factor (b) × (c) CumulativeLoss Ratio (d) × (e) Factor (b) × (g) CumulativeLoss Ratio (h) × (i) Policy YearLoss Ratio 1 2.770 0.442 0.000 0.000 0.4 2 4.175 0.493 0.000 0.000 0.55 3 4.175 0.493 1.194 0.659 0.65 4 4.175 0.493 2.245 0.669 0.67 5 4.175 0.493 3.170 0.678 0.69 6 4.175 0.493 3.998 0.686 0.71 7 4.175 0.493 4.754 0.695 0.73 8 4.175 0.493 5.445 0.702 0.75 9 4.175 0.493 6.075 0.708 0.76 10 4.175 0.493 6.650 0.713 0.76 11 4.175 0.493 7.176 0.717 0.76 12 4.175 0.493 7.655 0.720 0.77 13 4.175 0.493 8.093 0.723 0.77 14 4.175 0.493 8.493 0.725 0.77 15+6 4.175 0.493 8.684 0.725 0.77 ________ ________ ________ ________ Total: (k): (l): (m): (n): The purpose of this form is to report the following information on each resident of this state who has in force more than one Medicare supplement policy or certificate. The information is to be grouped by individual policyholder. FORM FOR REPORTINGMEDICARE SUPPLEMENT POLICIES Company name: ________________________________________ Address: ________________________________________ ________________________________________ Phone Number: ________________________________________ Due: March 1, annually Policy andCertificate # Date ofIssuance If any regulations of this chapter or the application of these regulations to any person or circumstance is for any reason held to be invalid, the remainder of the chapter and the application of the regulations to other persons or circumstances may not be affected. Instructions. Section 1882(d) of the federal Social Security Act (42 U.S.C. 1395ss) prohibits the sale of a health insurance policy (the term policy includes certificate) to Medicare beneficiaries that duplicates Medicare benefits unless it will pay benefits without regard to a beneficiary's other health coverage and it includes the prescribed disclosure statement on or together with the application for the policy. All types of health insurance policies that duplicate Medicare shall include one of the attached disclosure statements, according to the particular policy type involved, on the application or together with the application. The disclosure statement may not vary from the attached statements in terms of language or format (type size, type proportional spacing, bold character, line spacing, and usage of boxes around text). State and federal law prohibits insurers from selling a Medicare supplement policy to a person that already has a Medicare supplement policy except as a replacement. Property/casualty and life insurance policies are not considered health insurance. Disability income policies are not considered to provide benefits that duplicate Medicare. Long-term care insurance policies that coordinate with Medicare and other health insurance are not considered to provide benefits that duplicate Medicare. The federal law does not preempt state laws that are more stringent than the federal requirements. The federal law does not preempt existing state form filing requirements. Section 1882 of the federal Social Security Act was amended in subsection (d)(3)(A) to allow for alternative disclosure statements. The disclosure statements already in §B of this regulation remain. Carriers may use either disclosure statement with the requisite insurance product. However, carriers shall use either the original disclosure statements or the alternative disclosure statements and not use both simultaneously. Insurers shall use the disclosure statements found in §§B and C of this regulation if the disclosure statement was printed before January 1, 2006. Original Disclosure Statements. Accidental Injury Only Policies. The following is an original disclosure statement for policies that provide benefits for expenses incurred for an accidental injury only: Specified Limited Services Policies. The following is an original disclosure statement for policies that provide benefits for specified limited services: Expense Incurred Specified Disease Policies. The following is an original disclosure statement for policies that reimburse expenses incurred for specified disease(s) or other specified impairment(s). This includes expense incurred cancer, specified disease and other types of health insurance policies that limit reimbursement to named medical conditions. Fixed Dollar Specified Disease Policies. The following is an original disclosure statement for policies that pay fixed dollar amounts for specified diseases or other specified impairments. This includes cancer, specified disease, and other health insurance policies that pay a scheduled benefit or specific payment based on diagnosis of the conditions named in the policy. Policies Providing Both Expense Incurred and Fixed Indemnity Benefits. The following is an Original disclosure statement for policies that provide benefits for both expenses incurred and fixed indemnity basis: Policies Providing Fixed Dollar Benefits. The following is an original disclosure statement for indemnity policies and other policies that pay a fixed dollar amount per day, excluding long-term care policies: Other Health Insurance Policies. The following is an original disclosure statement for other health insurance policies not specifically identified in the previous statements: Alternative Disclosure Statements. Accidental Injury Only Policies. The following is an alternative disclosure statement for policies that provide benefits for expenses incurred for an accidental injury only: Specified Limited Services Policies. The following is an alternative disclosure statement for policies that provide benefits for specified limited services: Expense Incurred Specified Disease Policies. The following is an alternative disclosure statement for policies that reimburse expenses incurred for specified diseases or other specified impairments. This includes expense-incurred cancer, specified disease, and other types of health insurance policies that limit reimbursement to named medical conditions. Fixed Dollar Specified Disease Policies. The following is an alternative disclosure statement for policies that pay fixed dollar amounts for specified diseases or other specified impairments. This includes cancer, specified disease, and other health insurance policies that pay a scheduled benefit or specific payment based on diagnosis of the conditions named in the policy. Policies Providing Both Expense Incurred and Fixed Indemnity Benefits. The following is an alternative disclosure statement for policies that provide benefits upon both an expense-incurred and fixed indemnity basis: Policies Providing Only Fixed Dollar Benefits. The following is an alternative disclosure statement for indemnity policies and other policies that pay a fixed dollar amount per day, excluding long-term care policies: Other Health Insurance Policies. The following is an alternative disclosure statement for other health insurance policies not specifically identified in the preceding statements: Instructions. The instructions found in Regulation .22A(1)—(8) of this chapter also apply to the disclosure statements printed after December 31, 2005. Use of Original or Alternative Disclosure Statements. Section 1882 of the federal Social Security Act was amended in Subsection (d)(3)(A) to allow for alternative disclosure statements. Carriers may use either disclosure statement with the requisite insurance product. Carriers shall use either the original disclosure statements or the alternative disclosure statement, but not both simultaneously. Insurers shall use the disclosure statements found in §§C and D of this regulation if the disclosure statements were printed after December 31, 2005. Original Disclosure Statements. Accidental Injury Only Policies. The following is an original disclosure statement for policies that provide benefits for expenses incurred for an accidental injury only: Specified Limited Services Policies. The following is an original disclosure statement for policies that provide benefits for specified limited services: Expense Incurred Specified Disease Policies. The following is an original disclosure statement for policies that reimburse expenses incurred for specified diseases or other specified impairments. This includes expense-incurred cancer, specified disease, and other types of health insurance policies that limit reimbursement to named medical conditions. Fixed Dollar Specified Disease Policies. The following is an original disclosure statement for policies that pay fixed dollar amounts for specified diseases or other specified impairments. This includes cancer, specified disease, and other health insurance policies that pay a scheduled benefit or specific payment based on diagnosis of the conditions named in the policy. Policies Providing Fixed Dollar Benefits. The following is an original disclosure statement for indemnity policies and other policies that pay a fixed dollar amount per day, excluding long-term care policies: Policies Providing Both Expense Incurred and Fixed Indemnity Benefits. The following is an original disclosure statement for policies that provide benefits upon both an expense-incurred and fixed indemnity basis: Other Health Insurance Policies. The following is an original disclosure statement for other health insurance policies not specifically identified in the statements set forth in §C(1)-6) of this regulation: Alternative Disclosure Statements. Accidental Injury Only Policies. The following is an alternative disclosure statement for policies that provide benefits for expenses incurred for an accidental injury only: Specified Limited Services Policies. The following is an alternative disclosure statement for policies that provide benefits for specified limited services: Expense-Incurred Specified Disease Policies. The following is an alternative disclosure statement for policies that reimburse expenses incurred for specified diseases, or other specified impairments. This includes expense-incurred cancer, specified disease, and other types of health insurance policies that limit reimbursement to named medical conditions. Fixed Dollar Specified Disease Policies. The following is an alternative disclosure statement for policies that pay fixed dollar amounts for specified diseases or other specified impairments. This includes cancer, specified disease, and other health insurance policies that pay a scheduled benefit or specific payment based on diagnosis of the conditions named in the policy. Policies Providing Only Fixed Dollar Benefits. The following is an alternative disclosure statement for indemnity policies and other policies that pay a fixed dollar amount per day, excluding long-term care policies: Policies Providing Both Expense-Incurred and Fixed Indemnity Benefits. The following is an alternative disclosure statement for policies that provide benefits upon both an expense-incurred and fixed indemnity basis: Other Health Insurance Policies. The following is an alternative disclosure statement for other health insurance policies not specifically identified in the statements set forth in §D(1)-(6) of this regulation: Applicability. This regulation applies to Medicare Select policies and certificates, as defined in Regulation .02 of this chapter. A policy or certificate may not be advertised as a Medicare Select policy or certificate unless it meets the requirements of this regulation. The Commissioner may authorize an issuer to offer a Medicare Select policy or certificate pursuant to this regulation and §4358 of the Omnibus Budget Reconciliation Act (OBRA) of 1990 if the Commissioner finds that the issuer has satisfied all of the requirements of this regulation. A Medicare Select issuer may not issue a Medicare Select policy or certificate in Maryland until its plan of operation has been approved by the Commissioner. Required Filing of Plan of Operation. A Medicare Select issuer shall file a proposed plan of operation with the Commissioner and with the Secretary of the Maryland Department of Health in a format prescribed by the Commissioner. The plan of operation filed with the Commissioner shall contain at least the following information: A statement or map providing a clear description of the service area; A description of the grievance procedure to be utilized; Copies of the written information proposed to be used by the issuer to comply with Regulation .25B of this chapter; and Any other information requested by the Commissioner. The plan of operation filed with the the Secretary of the Maryland Department of Health shall contain, at a minimum, the following information: Evidence that all covered services subject to restricted network provisions are available and accessible through network providers, including a demonstration that: Services can be provided by network providers with reasonable promptness with respect to geographic location, hours of operation, and after-hours care; The number of network providers in the service area is sufficient, with respect to current and expected policyholders, either to deliver adequately all services that are subject to a restricted network provision or to make appropriate referrals; There are written agreements with network providers describing specific responsibilities; Emergency care is available 24 hours per day and 7 days per week; and 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 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; A statement or map providing a clear description of the service area; A description of the quality assurance program, including: The formal organizational structure; The written criteria for selection, retention and removal of network providers; and The procedures for evaluating quality of care provided by network providers, and the process to initiate corrective action if warranted; and A list and description, by specialty, of the network providers. In determining the reasonable promptness of services provided with respect to geographic location in §D(3)(a)(i) of this regulation, the geographic availability shall reflect the usual travel times within the community. In determining the reasonable promptness of services provided with respect to hours of operation and after-hours care in §D(3)(a)(i) of this regulation, the hours of operation and availability of after-hours care shall reflect usual practice in the local area. With respect to the requirements in §D(3)(a)(v) of this regulation that prohibit providers from billing or otherwise seeking reimbursement from or recourse against any individual insured under a Medicare Select policy or certificate, the prohibition is not required to be applied to supplemental charges or coinsurance amounts stated in the Medicare Select policy or certificate. The Secretary of the Maryland Department of Health shall notify the Commissioner in writing after the determining that the plan of operation filed by the issuer is acceptable. Required Filing of Changes to Plan of Operation. In General. A Medicare Select issuer shall file with the Commissioner any proposed changes to the plan of operation, except for changes to the list of network providers, prior to implementing the changes. Changes shall be deemed approved by the Commissioner after 30 days unless specifically disapproved. A Medicare Select issuer shall file an updated list of network providers with the Secretary of the Maryland Department of Health at least quarterly. The Secretary of the Maryland Department of Health shall notify the Commissioner in writing if the updated list of providers submitted in accordance with §E(2) of this regulation ceases to meet the criteria set forth in §D(3)(a) of this regulation. A Medicare Select policy or certificate may not restrict payment for covered services provided by nonnetwork providers if: The services are for symptoms requiring emergency care or are immediately required for an unforeseen illness, injury, or condition; and It is not reasonable to obtain services through a network provider. 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. 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. Applicability. This regulation shall apply to Medicare Select policies and certificates, as defined in Regulation .02 of this chapter. A policy or certificate may not be advertised as a Medicare Select policy or certificate unless it meets the requirements of this regulation. Required Disclosure. 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. The disclosure required by §B(1) of this regulation shall include at least the following: An outline of coverage sufficient to permit the applicant to compare the coverage and premiums of the Medicare Select policy or certificate with: Other Medicare supplement policies or certificates offered by the issuer; and Other Medicare Select policies or certificates; A description, including address, phone number, and hours of operation, of the network providers, including primary care physicians, specialty physicians, hospitals, and other providers; A description of the restricted network provisions, including payments for coinsurance and deductibles if providers other than network providers are utilized; A description of coverage for emergency and urgently needed care and other out-of-service-area coverage; A description of limitations on referrals to restricted network providers and to other providers; A description of the policyholder's rights to purchase any other Medicare supplement policy or certificate otherwise offered by the issuer; and A description of the Medicare Select issuer's quality assurance program and grievance procedure. With regard to the description of restricted network provisions required by §B(2)(c) of this regulation, expenses incurred when using out-of-network providers may not count toward the out-of-pocket annual limit contained in plans K and L, except to the extent specified in the policy or certificate. Before 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 under §B of this regulation and that the applicant understands the restrictions of the Medicare Select policy or certificate. Complaints and Grievances. Procedures Required. A Medicare Select issuer shall have and use procedures for hearing complaints and resolving written grievances from the subscribers. The procedures for hearing complaints and resolving written grievances from subscribers shall be aimed at mutual agreement for settlement. The grievance procedure shall be described in the policy and certificates and in the outline of coverage. Any grievance procedure involving coverage decisions shall comply with the requirements found in Insurance Article, Title 15, Subtitle 10D, Annotated Code of Maryland. Any grievance procedure involving adverse decisions shall comply with the requirements found in Insurance Article, Title 15, Subtitle 10A, Annotated Code of Maryland. 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. An issuer shall consider grievances in a timely manner and shall transmit the grievances to appropriate decision-makers who have authority to fully investigate the issue and take corrective action. If a grievance is found to be valid, an issuer shall take corrective action promptly. An issuer shall notify all concerned parties about the results of a grievance. Annual Report. The issuer shall report not later than March 31 of each year to the Commissioner regarding its grievance procedure. The report required by §D(9)(a) of this regulation 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. 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. Right to Purchase Medicare Supplement Policy or Certificate. 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 available the policies or certificates described in §F(1) of this regulation without requiring evidence of insurability after the Medicare Select policy or certificate has been in force for 6 months. For the purposes of §F(1) of this regulation, a Medicare supplement policy or certificate shall be considered to have comparable or lesser benefits unless the Medicare supplement policy or certificate contains one or more significant benefits not included in the Medicare Select policy or certificate being replaced. A benefit shall be considered a significant benefit under §F(3) of this regulation if the benefit includes coverage for the Medicare Part A deductible, coverage for at-home recovery services, or coverage for Part B excess charges. Options if the Medicare Select Program is Discontinued. Medicare Select policies and certificates shall provide for continuation of coverage in the event the Secretary determines that Medicare Select policies and certificates issued under this regulation shall be discontinued due to either the: Failure of the Medicare Select Program to be reauthorized under law; or Substantial amendment of the Medicare Select Program. If the Secretary determines that Medicare Select policies and certificates should be discontinued as described in §G(1) of this regulation, 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 referenced in §G(2) of this regulation shall make available the policies and certificates without requiring evidence of insurability. For the purposes of §G(2) of this regulation, a Medicare supplement policy or certificate shall 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. A benefit shall be considered a significant benefit under §G(4) of this regulation if the benefit includes coverage for the Medicare Part A deductible, coverage for at-home recovery services or coverage for Part B excess charges. This regulation applies to all policies with policy years beginning on or after July 1, 2009. Definitions. In this regulation, the following terms have the meanings indicated. Terms Defined. “Family member” means, with respect to an individual, any other individual who is a first-degree, second-degree, third-degree, or fourth-degree relative of the individual. Genetic Information. “Genetic information” means, with respect to an individual, information about the individual's genetic tests, the genetic tests of a family member of the individual, and the manifestation of a disease or disorder in a family member of the individual. “Genetic information” includes, with respect to an individual, a request for, or receipt of, genetic services, or participation in clinical research that includes genetic services, by the individual or a family member of the individual. “Genetic information” includes, with respect to a pregnant woman, genetic information of a fetus carried by the pregnant woman, “Genetic information” includes, with respect to an individual or family member utilizing reproductive technology, genetic information of an embryo legally held by the individual or family member. “Genetic information” does not include information about the sex or age of an individual. “Genetic services” means: A genetic test; Genetic counseling, including obtaining, interpreting, or assessing genetic information; or Genetic education. Genetic Test. “Genetic test” means an analysis of human DNA, RNA, chromosomes, proteins, or metabolites that detects genotypes, mutations, or chromosomal changes. “Genetic test” does not mean an analysis of proteins or metabolites that does not detect genotypes, mutations, or chromosomal changes. “Genetic test” does not mean an analysis of proteins or metabolites that is directly related to a manifested disease, disorder, or pathological condition that could reasonably be detected by a health care professional with appropriate training and expertise in the field of medicine involved. Issuer of a Medicare Supplement Policy or Certificate. “Issuer of a Medicare supplement policy or certificate” means an insurance company, fraternal benefit society, nonprofit health service plan, health maintenance organization, or any other entity delivering or issuing for delivery in this State Medicare supplement policies or certificates. “Issuer of a Medicare supplement policy or certificate” includes a third-party administrator or other person acting for or on behalf of an entity described in §B(2)(e)(i) of this regulation. “Underwriting purposes” means: Rules for, or determination of, eligibility, including enrollment and continued eligibility, for benefits under the policy; The computation of premium or contribution amounts under the policy; The application of a preexisting condition exclusion under the policy; and Other activities related to the creation, renewal, or replacement of a contract of health insurance or health benefits. An issuer of a Medicare supplement policy or certificate may not: Deny or condition the issuance or effectiveness of the policy or certificate, including the imposition of an exclusion of benefits under the policy or certificate because of a preexisting condition, based on the genetic information with respect to an individual; Discriminate in the pricing of the policy or certificate, including the adjustment of premium rates, of an individual based on the genetic information with respect to the individual; Request or require an individual or a family member of the individual to undergo a genetic test; Request, require, or purchase genetic information for underwriting purposes; or Request, require, or purchase, in connection with an enrollment, genetic information with respect to an individual before the individual's enrollment under the policy. The prohibitions described in §C(1) and (2) of this regulation do not limit the ability of an issuer of a Medicare supplement policy or certificate, to the extent otherwise permitted by law, from: Denying or conditioning the issuance or effectiveness of the policy or certificate or increasing the premium for a group based on the manifestation of a disease or disorder of an insured or applicant; or Increasing the premium for a policy issued to an individual based on the manifestation of a disease or disorder of an individual who is covered under the policy, but the manifestation of a disease or disorder in one individual may not also be used as genetic information about other group members and to further increase the premium for the group. The prohibition described in §C(3) of this regulation does not preclude an issuer of a Medicare supplement policy or certificate from obtaining and using the results of a genetic test in making a determination regarding payment, as defined for the purposes of applying the regulations promulgated under Part C of Title XI and Section 264 of the Health Insurance Portability and Accountability Act of 1996, and consistent with §C(1) and (2) of this regulation. For purposes of carrying out §E of this regulation, an issuer of a Medicare supplement policy or certificate may request only the minimum amount of information necessary to accomplish the intended purpose. Notwithstanding §C(3) of this regulation, an issuer of a Medicare supplement policy or certificate may request, but not require, that an individual or a family member of the individual undergo a genetic test if all of the following conditions are met: The request is made pursuant to research that complies with Part 46 of Title 45, Code of Federal Regulations, or equivalent federal regulations, and any applicable State or local law or regulations for the protection of human subjects in research; The issuer clearly indicates to the individual, or in the case of a minor child, to the legal guardian of the child, to whom the request is made that: Compliance with the request is voluntary, and Noncompliance with the request will have no effect on enrollment status or premium or contribution amounts; The issuer does not use genetic information collected or acquired under §G of this regulation to underwrite, determine eligibility to enroll or maintain enrollment status, set premium rates, or determine whether to issue, renew, or replace a policy or certificate; The issuer notifies the Secretary in writing that the issuer is conducting activities under the exception provided by §G of this regulation, and includes a description of the activities conducted; and The issuer complies with all other conditions for activities conducted under §G of this regulation, as the Secretary may require by regulation. If an issuer of a Medicare supplement policy or certificate obtains genetic information incidental to the requesting, requiring, or purchasing of other information concerning an individual, the request, requirement, or purchase will not be considered a violation of §C(5) of this regulation if the request, requirement, or purchase does not violate §C(4) of this regulation. General Standards. The standards found in §§B—D of this regulation 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. A policy or certificate may not be advertised, solicited, delivered, or issued for delivery in this State as a Medicare supplement policy or certificate on or after June 1, 2010, unless it complies with the benefit standards found in this regulation. An issuer may not offer a 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 before June 1, 2010, remain subject to the requirements of Regulation .08 of this chapter. Required Standards. The standards in this section apply to Medicare supplement policies and certificates and are in addition to all other requirements of this chapter. A Medicare supplement policy or certificate may not exclude or limit benefits for a loss incurred more than 6 months after the effective date of coverage because the loss 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 6 months before the effective date of coverage. A Medicare supplement policy or certificate may not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents. 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 the changes to the cost-sharing amounts. A Medicare supplement policy or certificate may not provide for termination of coverage of a spouse solely because of the occurrence of an event specified for termination of coverage of the insured, other than the nonpayment of premium. Each Medicare supplement policy shall be guaranteed renewable. The issuer may not: Cancel or nonrenew the policy solely on the ground of the health status of the individual; or Cancel or nonrenew the policy for any reason other than nonpayment of premium or material misrepresentation. If the Medicare supplement policy is terminated by the group policyholder and is not replaced as provided under §B(9) of this regulation, the issuer shall offer each certificate holder an individual Medicare supplement policy, which at the option of the certificate holder provides for: Continuation of the benefits contained in the group policy; or Benefits that meet the requirements of these regulations. If an individual is a certificate holder in a group Medicare supplement policy and the individual terminates membership in the group, the issuer shall: Offer the certificate holder the conversion option described in §B(7) of this regulation; or At the option of the group policyholder, offer the certificate holder continuation of coverage under the group policy. 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 each individual covered under the old group policy on the group policy's date of termination. Coverage under the new policy may not result in an exclusion for a preexisting condition that would have been covered under the group policy being replaced. Extension of Benefits. Termination of a Medicare supplement policy or certificate shall be without prejudice to a continuous loss that 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 on 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 may not be considered in determining a continuous loss under §B(10)(a) of this regulation. Suspension of Benefits. 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 a period not to exceed 24 months in which the policyholder or certificate holder has applied for and is determined to be entitled to medical assistance under Title XIX of the Social Security Act, but only if the policyholder or certificate holder notifies the issuer of the policy or certificate within 90 days after the date the individual becomes entitled to medical assistance. If the suspension described in §B(11)(a) of this regulation occurs and if the policyholder or certificate holder loses entitlement to medical assistance under Title XIX of the Social Security Act, the policy or certificate shall be reinstituted automatically, effective as of the date of termination of entitlement, if the policyholder or certificate holder provides notice of loss of entitlement within 90 days after the date of loss of entitlement and pays the premium attributable to the period, effective as of the date of termination of entitlement. A 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 §226 (b) of the Social Security Act; and Covered under a group health plan as defined in §1862(b)(1)(A)(v) of the Social Security Act. If the suspension described in §B(11)(c) of this regulation occurs and if the policyholder or certificate holder loses coverage under the group health plan, the policy shall be reinstituted automatically, effective as of the date of loss of coverage under the group health plan, if the policyholder described in §B(11)(c): Provides notice of loss of coverage within 90 days after the date of the loss of group coverage; and Pays the premium attributable to the period, effective as of the date of termination of enrollment in the group health plan. Reinstitution of coverage under §B(11)(b) or (d) of this regulation: May not provide for any waiting period with respect to treatment of preexisting conditions; Shall provide for resumption of coverage that is substantially equivalent to coverage in effect before the date of suspension; and 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. Standards for Basic (Core) Benefits Common to 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: Coverage of Part A Medicare eligible expenses for hospitalization to the extent not covered by Medicare from the 61st day through the 90th day in any Medicare benefit period; 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; Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 100 percent 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; Coverage under Medicare Parts A and B for the reasonable cost of the first 3 pints of blood, or equivalent quantities of packed red blood cells, as defined under federal regulations, unless replaced in accordance with federal regulations; 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; and Coverage of cost sharing for all Part A Medicare eligible hospice care and respite care expenses. The provider shall accept the issuer's payment of the Medicare Part A eligible expenses for hospitalization under §C(1)(c) of this regulation as payment in full and may not bill the insured for any balance. 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 instead of it. 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 Regulation .28 of this chapter: Medicare Part A Deductible—Coverage for 100 percent of the Medicare Part A inpatient hospital deductible amount per benefit period; Medicare Part A Deductible—Coverage for 50 percent of the Medicare Part A inpatient hospital deductible amount per benefit period; Skilled Nursing Facility Care—Coverage for the actual billed charges up to the coinsurance amount 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; Medicare Part B Deductible—Coverage for 100 percent of the Medicare Part B deductible amount per calendar year regardless of hospital confinement; 100 Percent 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; and Medically Necessary Emergency Care in a Foreign Country—Coverage to the extent not covered by Medicare for 80 percent 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 60 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” means care needed immediately because of an injury or an illness of sudden and unexpected onset. Definitions. In this regulation, the following term has the meaning indicated. Term Defined. “Structure, language, and format” means style, arrangement, and overall content of a benefit. General Standards. The standards found in §§C—I of this regulation 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. A policy or certificate may not be advertised, solicited, delivered, or issued for delivery in this State as a Medicare supplement policy or certificate unless it complies with the benefit plan standards set forth in this regulation. 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 Regulation .09 of this chapter. 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 Regulation .27C of this chapter. If an issuer makes available any of the additional benefits described in Regulation .27D of this chapter, or offers standardized benefit Plans K or L, as described in §H(8) and (9) of this regulation, then the issuer shall make available to each prospective policyholder and certificate holder: A policy form or certificate form with only the core benefits as described in §C of this regulation; and A policy form or certificate form containing either standardized benefit Plan C, as described in §H(3) of this regulation, or standardized benefit Plan F, as described in §H(5) of this regulation. Groups, packages, or combinations of Medicare supplement benefits other than those listed in this regulation may not be offered for sale in this State, except as may be permitted in §I of this regulation and Regulation .24 of this chapter. Structure of Benefits. Benefit plans shall be uniform in structure, language, designation, and format to the standard benefit plans listed in this regulation and conform to the definitions in Regulation .02 of this chapter. Each benefit shall be structured in accordance with the format provided in Regulation .27C and D of this chapter, or in the case of plans K or L in §H(8) and (9) of this regulation, and shall list the benefits in the order shown in this regulation. An issuer may use, in addition to the benefit plan designations required in §F of this regulation, other designations to the extent permitted by law. Make-up of 2010 Standardized Benefit Plans. Standardized Medicare supplement benefit Plan A shall include only the following: The core benefits as defined in Regulation .27C of this chapter. Standardized Medicare supplement benefit Plan B shall include only the following: The core benefits as defined in Regulation .27C of this chapter, plus 100 percent of the Medicare Part A Deductible as defined in Regulation .27D(1) of this chapter. Standardized Medicare supplement benefit Plan C shall include only the following: The core benefits as defined in Regulation .27C of this chapter, plus 100 percent of the Medicare Part A Deductible, Skilled Nursing Facility Care, 100 percent of the Medicare Part B Deductible, and Medically Necessary Emergency Care in a Foreign Country as defined in Regulation .27D(1), (3), (4), and (6) of this chapter. Standardized Medicare supplement benefit Plan D shall include only the following: The core benefits as defined in Regulation .27C of this chapter, plus 100 percent of the Medicare Part A Deductible, Skilled Nursing Facility Care, and Medically Necessary Emergency Care in an Foreign Country as defined in Regulation .27D(1), (3), and (6) of this chapter. Standardized Medicare supplement benefit Plan F shall include only the following: The basic core benefits as defined in Regulation .27C of this chapter, plus 100 percent of the Medicare Part A Deductible, Skilled Nursing Facility Care, 100 percent of the Medicare Part B Deductible, 100 percent of the Medicare Part B Excess Charges, and Medically Necessary Emergency Care in a Foreign Country as defined in Regulation .27D(1) and (3)—(6) of this chapter. Standardized Medicare Supplement Benefit Plan F With High Deductible. Plan F with High Deductible shall include only 100 percent of covered expenses following the payment of the annual deductible set forth in §H(6)(c) of this regulation. The covered expenses include the core benefits as defined in Regulation .27C of this chapter, plus 100 percent of the Medicare Part A Deductible, Skilled Nursing Facility Care, 100 percent of the Medicare Part B Deductible, 100 percent of the Medicare Part B Excess Charges, and Medically Necessary Emergency Care in a Foreign Country as defined in Regulation .27D(1) and (3)—(6) of this chapter. Annual Deductible. The annual deductible in Plan F with High Deductible shall consist of out-of-pocket expenses, other than premiums, for services covered by Plan F, and is in addition to any other specific benefit deductibles. The basis for the deductible is $1,500. The Secretary shall adjust the deductible annually after 1999 to reflect the change in the Consumer Price Index for all urban consumers for the 12-month period ending with August of the preceding year, and rounded to the nearest multiple of $10. Standardized Medicare Supplement Benefit Plan G. Standardized Medicare supplement benefit Plan G shall include only the following: The core benefits as defined in Regulation .27C of this chapter, plus 100 percent of the Medicare Part A Deductible, Skilled Nursing Facility Care, 100 percent of the Medicare Part B Excess Charges, and Medically Necessary Emergency Care in a Foreign Country as defined in Regulation .27D(1), (3), (5), and (6) of this chapter. Effective January 1, 2020, the standardized benefit plan described in Regulation .31B(3) of this chapter (Re-designated Plan G High Deductible) may be offered to any individual who was eligible for Medicare prior to January 1, 2020. Standardized Medicare Supplement Benefit Plan K. Plan K is mandated by the Medicare Prescription Drug, Improvement and Modernization Act of 2003. Plan K shall include only the following: Part A Hospital Coinsurance 61st Through 90th Days — Coverage of 100 percent of the Part A hospital coinsurance amount for each day used from the 61st through the 90th day in any Medicare benefit period; Part A Hospital Coinsurance 91st Through 150th Days — Coverage of 100 percent 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; Part A Hospitalization After Lifetime Reserve Days are Exhausted — Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 100 percent 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; Medicare Part A Deductible — Coverage for 50 percent of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in §H(8)(b)(x) of this regulation; Skilled Nursing Facility Care — Coverage for 50 percent 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 §H(8)(b)(x) of this regulation; Hospice Care — Coverage for 50 percent of cost sharing for all Part A Medicare eligible expenses and respite care until the out-of-pocket limitation is met as described in §H(8)(b)(x) of this regulation; Blood — Coverage for 50 percent, under Medicare Part A or B, of the reasonable cost of the first 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 §H(8)(b)(x) of this regulation; Part B Cost Sharing — Except for coverage provided in §H(8)(b)(ix) of this regulation, coverage for 50 percent 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 §H(8)(b)(x) of this regulation; Part B Preventive Services — Coverage of 100 percent of the cost sharing for Medicare Part B preventive services after the policyholder pays the Part B deductible; and Cost Sharing After Out-of-Pocket Limit — Coverage of 100 percent 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. The provider shall accept the issuer's payment of the Medicare Part A eligible expenses for hospitalization under §H(8)(b)(iii) of this regulation as payment in full and may not bill the insured for any balance. Standardized Medicare Supplement Benefit Plan L. Plan L is mandated by The Medicare Prescription Drug, Improvement and Modernization Act of 2003. Plan L shall include only the following: The benefits described in §H(8)(b)(i)—(iii) and (ix) of this regulation; The benefit described in §H(8)(b)(iv)—(viii) of this regulation, but substituting 75 percent for 50 percent; and The benefit described in §H(8)(b)(x) of this regulation, but substituting $2,000 for $4,000. Standardized Medicare supplement benefit Plan M shall include only the following: The core benefits as defined in Regulation .27C of this chapter, plus 50 percent of the Medicare Part A Deductible, Skilled Nursing Facility Care, and Medically Necessary Emergency Care in a Foreign Country as defined in Regulation .27D(2), (3), and (6) of this chapter. Standardized Medicare Supplement Benefit Plan N. Plan N shall include only the following: The core benefits as defined in Regulation .27C of this chapter, plus 100 percent of the Medicare Part A Deductible, Skilled Nursing Facility Care, and Medically Necessary Emergency Care in a Foreign Country as defined in Regulation .27D(1), (3), and (6) of this chapter, with copayments in the following amounts: 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 The lesser of $50 or the Medicare Part B coinsurance or copayment for each covered emergency room visit. The copayment described in §H(11)(a)(ii) of this regulation shall be waived if the insured is admitted to a hospital and the emergency visit is subsequently covered as a Medicare Part A expense. 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 described in §I(1) of this regulation 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 may not adversely impact the goal of Medicare supplement simplification. New or innovative benefits may not include an outpatient prescription drug benefit. New or innovative benefits may not be used to change or reduce benefits, including a change of any cost-sharing provision, in any standardized plan. Forms. General Standards. A policy or certificate that provides coverage of the Medicare Part B deductible may not 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. Medicare supplement policies and certificates delivered or issued for delivery to individuals eligible for Medicare before January 1, 2020 remain subject to the requirements of Regulation .28 of the chapter. Medicare supplement policies or certificates delivered or issued for delivery to individuals newly eligible for Medicare on or after January 1, 2020 are subject to the requirements of Regulation .28 of this chapter, except as stated in §§B and C of this regulation. 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. Make-up of 2020 Standardized Benefit Plans Standardized Medicare supplement benefit Plan C is re-designated as Plan D and shall include the benefits contained in Regulation .28H(3) of this chapter except for coverage for 100 percent or any portion of the Medicare Part B deductible. Standardized Medicare supplement benefit Plan F is re-designated as Plan G and shall include the benefits contained in Regulation .28H(5) of this chapter except for coverage for 100 percent or any portion of the Medicare Part B deductible. Standardized Medicare Supplement Benefit Plan G With High Deductible. Standardized Medicare supplement benefit Plan F with High Deductible is re-designated as Plan G with High Deductible. Standardized Medicare supplement benefit Plan G with High Deductible shall include the benefits contained in Regulation .28H(6) of this chapter except for coverage for 100 percent or any portion of the Medicare Part B deductible. The Medicare Part B deductible paid by the beneficiary shall be considered an out-of-pocket expense in meeting the annual Plan G high deductible. In the case of an individual newly eligible for Medicare on or after January 1, 2020, the reference to Plans C or F in Regulation .28D(2) of this chapter is deemed a reference to Plans D or G, respectively. On or after January 1, 2020, the standardized benefit plan described in §B(3) of this regulation may be offered to an individual who was eligible for Medicare prior to January 1, 2020 in addition to the standardized plans described in Regulation .28H of this chapter. For purposes of Regulation .09-1E of this chapter, in the case of an individual newly eligible for Medicare on or after January 1, 2020, any reference to Plans C or F (including F With High Deductible) shall be deemed to be a reference to Plans D or G (including G With High Deductible) respectively. Health-General Article, §§19-705 and 19-706; Insurance Article, §§2-109 and 8-403(b), Title 15, Subtitle 9, and Title 27; Annotated Code of Maryland Effective date: Regulations .01—.21 adopted as an emergency provision effective July 14, 1992 (19:16 Md. R. 1466); adopted permanently effective August 3, 1992 (19:15 Md. R. 1389) Chapter revised effective April 1, 1996 (23:6 Md. R. 475) Regulation .14A amended, and Regulation .21 repealed, and Regulations .22 and .23 recodified to Regulations .21 and .22, respectively, as an emergency provision effective April 25, 1996 (23:10 Md. R. 728); amended permanently effective September 10, 1996 (23:18 Md. R. 1317) Chapter recodified from COMAR 09.30.90 to COMAR 31.10.06 effective September 7, 1998 (25:18 Md. R. 1439) Regulation .02 amended as an emergency provision effective January 1, 1999 (26:1 Md. R. 18); amended permanently effective March 22, 1999 (26:6 Md. R. 489) Regulation .02 amended as an emergency provision effective July 25, 2000 (27:16 Md. R. 1520); amended permanently effective November 13, 2000 (27:22 Md. R. 2061) Regulation .02 amended as an emergency provision effective October 1, 2001 (28:23 Md. R. 2053); emergency status expired March 29, 2002; amended permanently effective April 1, 2002 (29:6 Md. R. 570) Regulation .03 amended as an emergency provision effective January 1, 1999 (26:1 Md. R. 18); amended permanently effective March 22, 1999 (26:6 Md. R. 489) Regulation .04B amended as an emergency provision effective January 1, 2000 (27:4 Md. R. 452); emergency status expired June 28, 2000 Regulation .04B amended effective August 21, 2000 (27:16 Md. R. 1526) Regulation .06 amended as an emergency provision effective January 1, 1999 (26:1 Md. R. 18); amended permanently effective March 22, 1999 (26:6 Md. R. 489) Regulation .08 amended as an emergency provision effective July 25, 2000 (27:16 Md. R. 1520); amended permanently effective November 13, 2000 (27:22 Md. R. 2061) Regulation .08 amended as an emergency provision effective October 1, 2001 (28:23 Md. R. 2053); emergency status expired March 29, 2002; amended permanently effective April 1, 2002 (29:6 Md. R. 570) Regulation .09 amended as an emergency provision effective January 1, 1999 (26:1 Md. R. 18); amended permanently effective March 22, 1999 (26:6 Md. R. 489) Regulation .09-1 adopted as an emergency provision effective January 1, 1999 (26:1 Md. R. 18); adopted permanently effective March 22, 1999 (26:6 Md. R. 489) Regulation .09-1 amended as an emergency provision effective July 25, 2000 (27:16 Md. R. 1520); amended permanently effective November 13, 2000 (27:22 Md. R. 2061) Regulation .09-1 amended as an emergency provision effective October 1, 2001 (28:23 Md. R. 2053); emergency status expired March 29, 2002; amended permanently effective April 1, 2002 (29:6 Md. R. 570) Regulation .13 amended as an emergency provision effective January 1, 1999 (26:1 Md. R. 18); amended permanently effective March 22, 1999 (26:6 Md. R. 489) Regulation .13 amended as an emergency provision effective July 25, 2000 (27:16 Md. R. 1520); amended permanently effective November 13, 2000 (27:22 Md. R. 2061) Regulation .22 amended as an emergency provision effective January 1, 1999 (26:1 Md. R. 18); amended permanently effective March 22, 1999 (26:6 Md. R. 489) Regulation .23 adopted as an emergency provision effective October 1, 2001 (28:23 Md. R. 2053); emergency status expired March 29, 2002; adopted permanently effective April 1, 2002 (29:6 Md. R. 570) Regulation .24 adopted as an emergency provision effective October 1, 2001 (28:23 Md. R. 2053); emergency status expired March 29, 2002; adopted permanently effective April 1, 2002 (29:6 Md. R. 570) Chapter revised effective January 1, 2006 (32:18 Md. R. 1522) Regulation .02B amended effective September 21, 2009 (36:19 Md. R. 1439); January 14, 2019 (46:1 Md. R. 13) Regulation .06A amended effective August 21, 2023 (50:16 Md. R. 729) Regulation .07A amended effective September 21, 2009 (36:19 Md. R. 1439) Regulation .08 amended effective September 21, 2009 (36:19 Md. R. 1439) Regulation .09 amended effective September 21, 2009 (36:19 Md. R. 1439) Regulation .13 amended effective September 21, 2009 (36:19 Md. R. 1439) Regulation .13E amended effective November 29, 2010 (37:24 Md. R. 1660) Regulation .26 adopted effective June 29, 2009 (36:13 Md. R. 901) Regulations .27—.30 adopted effective September 21, 2009 (36:19 Md. R. 1439) Regulation .28H amended effective November 29, 2010 (37:24 Md. R. 1660); January 14, 2019 (46:1 Md. R. 13) Regulation .29 repealed effective November 29, 2010 (37:24 Md. R. 1660) Regulation .30 amended effective January 14, 2019 (46:1 Md. R. 13) Regulation .30I, J amended effective November 29, 2010 (37:24 Md. R. 1660) Regulation .31 adopted effective January 14, 2019 (46:1 Md. R. 13)