Section 71.09 - New or Innovative BenefitsAn Issuer of Medicare Supplement Insurance may, with the prior approval of the Commissioner, offer Medicare Supplement Insurance Policies with new or innovative benefits described in 211 CMR 71.09 in addition to the benefits provided in a Policy that otherwise complies with the applicable standards set forth in 211 CMR 71.00. The new or innovative benefits may include benefits that are appropriate to Medicare Supplement Insurance, new or innovative, not otherwise available, cost-effective, and offered in a manner which is consistent with the goal of simplification of Medicare Supplement Insurance Policies. Only those new and innovative benefits specified in 211 CMR 71.09 and any other new or innovative benefits approved by the Commissioner may be so offered. Nothing in 211 CMR 71.09 prohibits an Issuer offering a Policy with new or innovative benefits consistent with 211 CMR 71.09 from also providing a Policy of the same Medicare Supplement option type without the new or innovative benefit. Notwithstanding the provisions of any other section, a Medicare Supplement Insurance Policy with benefits for outpatient prescription drugs, including such benefits provided through Alternate Innovative Benefits Riders shall not be issued after December 31, 2005, but coverage in effect on December 31, 2005 shall be renewed, except as identified in 211 CMR 71.07(5).
(1)Individual Case Management. Issuers providing Medicare Supplement Insurance may provide coverage for services in addition to the benefits required by the Commissioner for the applicable Medicare Supplement Core Policy, Medicare Supplement 1 Policy, Medicare Supplement 1A Policy, or Medicare Supplement 2 Policy as part of an individual case management program. Such program must be approved by the Commissioner in advance. Such individual case management program may be established by the Issuer pursuant to a plan of care agreed to by the Insured and the attending physician and approved under the Issuer's individual case management program.(2)Outpatient Prescription Drug Benefits. In providing the Outpatient Prescription Drug benefits in a Medicare Supplement 2 Insurance Policy, an Issuer may limit benefits to those received from providers with which it has an agreement, provided that such limitation does not significantly reduce the availability of benefits under the Policy; and provided further, that any limitation or exclusion of a provider, and any such agreement, are in accordance with M.G.L. c. 176D, § 3B. For the purposes of 211 CMR 71.09(2), "Outpatient Prescription Drugs" includes insulin, as well as the needles, syringes, pumps and pump supplies necessary for the administration of insulin and blood sugar level testing equipment and supplies for use at home; drugs provided by a home infusion therapy provider; and drugs used on an off-label basis for the treatment of cancer or HIV/AIDS and medically necessary services associated with the administration of such drugs as required by M.G.L. c. 175, § 47K; M.G.L. c. 175, § 47L; M.G.L. c. 176A, § 8N; or M.G.L. c. 176B, § 4N, or by M.G.L. c. 175, § 47O; M.G.L. c. 175, § 47P; M.G.L. c. 176A, § 8Q (as added by St. 1996, c. 450, § 222); or by M.G.L. c. 176B, § 4P (as added by St. 1994, c. 60, § 146), and drugs and devices for hormone replacement therapy for peri- and post-menopausal women and for outpatient prescription contraceptive drugs or devices as required by M.G.L. c. 175, § 47W; M.G.L. c. 176A, § 8W or M.G.L. c. 176B, § 4W (as added by St. 2002, c. 49).(3)Mail Service Prescription Drug Program. Issuers providing Medicare Supplement Insurance Policies may provide coverage for a mail service prescription drug program for Outpatient Prescription Drugs for which federal law requires a prescription in addition to the benefits required by the Commissioner for a Medicare Supplement 2 Insurance Policy. The benefit must be approved by the Commissioner in advance; provided however, that the Insured shall only be charged a copayment and the Insured's copayments for Outpatient Prescription Drugs shall be either: (a) no higher than $8 for each generic prescription or refill and no higher than $15 for each brand name prescription or refill; or(b) no higher than $10 for each generic or brand name prescription or refill; and provided, further, that each such prescription or refill shall contain a minimum of 21 days' and a maximum of 90 days' supply. Nothing in 211 CMR 71.09(3) shall be construed to prevent such an Issuer from basing payment on allowed charges rather than on charges or limiting benefits to those received from providers with whom they have an agreement; provided that such limitation does not significantly reduce the availability of benefits under the Policy; and provided further, that any limitation or exclusion of a provider, and any such agreement, are in accordance with M.G.L. c. 176D, § 3B. For the purposes of 211 CMR 71.09(3), "Outpatient Prescription Drugs" includes insulin, as well as the needles, syringes, pumps and pump supplies necessary for the administration of insulin and blood sugar level testing equipment and supplies for use at home; drugs provided by a home infusion therapy provider; and drugs used on an off-label basis for the treatment of cancer or HIV/AIDS and medically necessary services associated with the administration of such drugs as required by M.G.L. c. 175, § 47K; M.G.L. c. 175, § 47L; M.G.L. c. 176A, § 8N; or M.G.L. c. 176B, § 4N; or by M.G.L. c. 175, § 47O; M.G.L. c. 175, § 47P; M.G.L. c. 176A, § 8Q (as added by St. 1996, c. 450, § 222); or by M.G.L. c. 176B, § 4P (as added by St. 1994, c. 60, § 146); and drugs and devices for hormone replacement therapy for peri- and post-menopausal women and for outpatient prescription contraceptive drugs or devices as required by M.G.L. c. 175, § 47W; M.G.L. c. 176A, § 8W or M.G.L. c. 176B, § 4W (as added by St. 2002, c. 49, §§ 4 and 5).
(4)Alternate Innovative Benefits. Issuers providing Medicare Supplement Insurance may provide alternate innovative benefits consisting of the innovative preventive care benefit described in 211 CMR 71.09(4)(a) or the innovative foreign travel care benefit described in 211 CMR 71.09(4)(b), in addition to the benefits required for a Medicare Supplement Core Insurance Policy, a Medicare Supplement 1 Insurance Policy or a Medicare Supplement 1A Insurance Policy, as applicable, subject to the prior approval of the Commissioner of Insurance. Alternate innovative benefits may be provided within a Medicare Supplement Insurance Policy or by an Alternate Innovative Benefit Rider to a Medicare Supplement Policy, provided, that each Issuer may offer only one combination of the benefits described in 211 CMR 71.09(4)(a) and (b) for each type of Medicare Supplement Insurance Policy. An Alternate Innovative Benefit Rider may be offered only in addition to the applicable Medicare Supplement Insurance Policy form required for a Medicare Supplement Core Insurance Policy, a Medicare Supplement 1 Insurance Policy or a Medicare Supplement 1A Insurance Policy, as applicable. (a)Innovative Preventive Care Benefit. Such innovative benefit shall contain the following benefits for preventive care:1.Preventive Vision Care Benefits, consisting of coverage for routine vision exams, including refractions, to determine the need for corrective lenses and related vision care supplies. These preventive vision care benefits may be limited to: one routine vision exam every two calendar years; and up to a benefit maximum of no less than $100 every two calendar years for frames and/or prescription lenses (or contact lenses). Nothing in 211 CMR 71.09(4)(a)1. shall be construed to prevent an Issuer from basing payment on allowed charges rather than on charges or limiting benefits to those received from an ophthalmologist or an optometrist with whom it has an agreement; provided that such limitation does not significantly reduce the availability of benefits under the Policy.2.Dental Care Benefits, consisting of coverage for routine dental services that may be limited to no less than one cleaning every six months. Nothing in 211 CMR 71.09(4)(a)2. shall be construed to prevent an Issuer from basing payment on allowed charges rather than on charges or limiting benefits to those received from a dentist with whom it has an agreement; provided that such limitation does not significantly reduce the availability of benefits under the Policy.3.Preventive Hearing Care Benefits, consisting of coverage for routine hearing exams and hearing aids. These preventive hearing care benefits may be limited to: one routine hearing exam every two calendar years; and up to a benefit maximum of no less than $200 every two calendar years for one hearing aid (or one set of binaural hearing aids), including dispensing fees, acquisition costs, batteries and repairs. Nothing in 211 CMR 71.09(4)(a)3. shall be construed to prevent an Issuer from basing payment on allowed charges rather than on charges or limiting benefits to those received from a provider or a hearing aid dealer with whom it has an agreement.4.Fitness or Weight Loss Program Benefits, consisting of reimbursement of no less than $150 each calendar year incurred in dues or membership fees for membership or exercise classes at a health club and/or reimbursement of no less than $150 each calendar year incurred in dues or fees for weight loss program membership or classes. Nothing in 211 CMR 71.09(4)(a)4. shall be construed to prevent an Issuer from limiting fitness benefits to reimbursement for dues or membership fees for membership or exercise classes at a health club with which it has an agreement or which it designates as approved, provided that such limitation does not significantly reduce the availability of benefits under the Policy. Nothing in 211 CMR 71.09(4)(b)4. shall be construed to prevent an Issuer from limiting weight loss program benefits to reimbursement for dues or fees for membership or classes at any hospital-based weight loss program and at any non-hospital-based weight loss program with which the Issuer has an agreement or which it designates as approved, provided that such limitation does not significantly reduce the availability of benefits under the Policy.(b)Innovative Foreign Travel Benefit. Such innovative benefit shall, for those insureds traveling outside the United States and its territories, provide coverage for the same services and the same level of payment as is provided within the United Stated by the combination of Medicare Part A and Part B and the Medicare Supplement Core Insurance Policy, less any Medicare payments.Amended by Mass Register Issue 1397, eff. 8/9/2019.