Conn. Agencies Regs. § 38a-495-10

Current through October 16, 2024

Section 38a-495-10 - Required disclosure provisions

(a)General Rules.

(1) Medicare supplement policies shall include a renewal or continuation provision. The language or specifications of such provision must be consistent with the type of contract issued. Such provision shall be appropriately captioned, and shall appear on the first page of the policy.

(2) Except for riders or endorsements by which the insurer 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 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 policy issue, any rider or endorsement which increases benefits or coverage with a concomitant increase in premium during the policy term must be agreed to in writing signed by the insured, unless the benefits are required by the minimum standards for Medicare supplement insurance policies, or if the increased benefits or coverage is required by law. Where a separate additional premium is charged for benefits provided in connection with riders or endorsements, such premium charge shall be set forth in the policy.

(3) A Medicare supplement policy which provides for the payment of benefits based on standards described as "usual and customary," "reasonable and customary" or words of similar import shall include a definition of such terms and an explanation of such terms in its accompanying outline of coverage.

(4) If a Medicare supplement policy contains any limitations with respect to preexisting conditions, such limitations must appear as a separate paragraph of the policy and be labeled as "Preexisting Condition Limitations."

(5) Medicare supplement policies or certificates shall have a notice prominently printed on the first page of the policy or certificate or attached thereto stating in substance that the policy or certificateholder shall have the right to return the policy or certificate within thirty (30) days of its delivery and to have the premium refunded in a reasonably prompt manner if, after examination of the policy or certificate, the insured person is not satisfied for any reason.

(6) Insurers issuing accident and sickness policies, certificates or subscriber contracts which provide hospital or medical expense coverage on an expense incurred or indemnity basis to a person(s) eligible for Medicare by reason of age shall provide to all applicants a Medicare supplement Buyer's Guide in the form developed jointly by the National Association of Insurance Commissioners and the Health Care Financing Administration. Delivery of the Buyer's Guide shall be made whether or not such policies, certificates or subscriber contracts are advertised, solicited or issued as Medicare supplement policies as defined in this regulation. Except in the case of direct response insurers, delivery of the Buyer's Guide shall be made to the applicant at the time of application and acknowledgement of receipt of the Buyer's Guide shall be obtained by the insurer. Direct response insurers shall deliver the Buyer's Guide to the applicant upon request but not later than at the time the policy is delivered.

(b)Notice Requirements.

(1) As soon as practicable, but no later than thirty (30) days prior to the annual effective date of any Medicare benefit changes, every insurer, health care service plan or other entity providing Medicare supplement insurance or benefits to a resident of this State shall notify its policyholders, contract holders and certificate holders of modifications it has made to Medicare supplement insurance policies or contracts in a format acceptable to the Commissioner or in the format prescribed in Appendix A, if no other format is prescribed by the Commissioner. Such notice shall:

(A) Include a description of revisions to the Medicare program and a description of each modification made to the coverage provided under the Medicare supplement insurance policy or contract, and

(B) Inform each covered person as to when any premium adjustment approved by the commissioner is to be made due to changes in Medicare.

(2) 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.

(3) Such notices shall not contain or be accompanied by any solicitation.

(c)Outline of Coverage Requirements for Medicare Supplement Policies.

(1) Insurers issuing Medicare supplement policies or certificates for delivery in this State shall provide an outline of coverage to all applicants at the time application is made and, except for direct response policies, shall obtain an acknowledgement of receipt of such outline from the applicant; and

(2) 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, a substitute outline of coverage properly describing the policy or certificate must accompany such policy or certificate when it is delivered and contain the following statement, in no less than twelve (12) point type, immediately above the company name:

"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."

(3) The outline of coverage provided to applicants pursuant to paragraphs (1) and (2) shall be in the form prescribed below:

[COMPANY NAME]

OUTLINE OF MEDICARE SUPPLEMENT COVERAGE AND PREMIUM INFORMATION

USE THIS OUTLINE TO COMPARE BENEFITS AND PREMIUMS AMONG POLICIES

1.	Read your Policy Carefully-This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY CAREFULLY!
2.	Medicare Supplement Coverage-Policies of this category are designed to supplement Medicare by covering some hospital, medical and surgical services which are partially covered by Medicare. Coverage is provided for hospital inpatient charges and some physician charges, subject to any deductibles and copayment provisions which may be in addition to those provided by Medicare, and subject to other limitations which may be set forth in the policy. The policy does not provide benefits for custodial care such as help in walking, getting in and out of bed, eating, dressing, bathing and taking medicine.
3.	A. [for agents:] Neither [insert company's name] nor its agents are connected with Medicare. B. [for direct responses:] [insert company's name] is not connected with Medicare.
4.	[A brief summary of the major medical benefit gaps in Medicare Parts A & B with a parallel description of supplemental benefits, including dollar amounts (and indexed copayments or deductibles, as appropriate), provided by the Medicare supplement coverage in the following order:]

DESCRIPTION	THIS POLICY PAYS**	YOU PAY
I. MINIMUM STANDARDS
SERVICE PART A
INPATIENT HOSPITAL SERVICES:
Semi-Private Room & Board
Miscellaneous Hospital Servivces & Supplies, such as Drugs, X-Rays, Lab Tests & Operating Room
SKILLED NURSING FACILITY CARE
BLOOD
HOME HEALTH SERVICES
PART B
MEDICAL EXPENSE:
Services of a Physician/ Outpatient Services Medical Supplies other than Prescribed Drugs
BLOOD
MAMMORGRAPHY SCREENING
MISCELLANEOUS Immunosuppresive Drugs
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
II. ADDITIONAL BENEFITS
PART A
DESCRIPTION	THIS POLICY PAYS**	YOU PAY
Part A Deductible
Private Rooms
In-Hospital Private Nurses
Skilled Nursing Facility Care
PARTS A & B
Part B Deductible
Medical Charges in Excess of Medicare Allowable Expenses (Percentage Paid)
OUT-OF-POCKET MAXIMUM
PRESCRIPTION DRUGS
MISCELLANEOUS
Respite Care Benefits Expenses Incurred in Foreign Country
Other:
TOTAL PREMIUM		$_________

IN ADDITION TO THIS OUTLINE OF COVERAGE, [INSURANCE COMPANY NAME] WILL SEND AN ANNUAL NOTICE TO YOU 30 DAYS PRIOR TO THE EFFECTIVE DATE OF MEDICARE CHANGES WHICH WILL DESCRIBE THESE CHANGES AND THE CHANGES IN YOUR MEDICARE SUPPLEMENT COVERAGE.

**If this policy does not provide coverage for a benefit listed above, the insurer must state "no coverage" beside that benefit in the first column.

5.	[The following chart shall accompany the outline of coverage:]
	[Company Name]
	Notice of Changes in Medicare and your Medicare Supplement Coverage-1990

The following chart briefly describes the modifications in Medicare and in your medicare supplement coverage. PLEASE READ CAREFULLY!

[A brief description of the revisions to Medicare parts A & B with a parallel description of supplemental benefits with subsequent changes, including dollar amounts, provided by the Medicare supplement coverage in substantially the following format.]

SERVICES	MEDICARE BENEFITS Effective January 1, 1990, Medicare Will Pay	YOUR MEDICARE SUPPLEMENT COVERAGE Effective January 1, 1990, Your Coverage Will Pay
MEDICARE PART A
SERVICES AND SUPPLIES
Inpatient Hospital Services	All but $592 for first 60 days/benefit period
Semi-Private Room & Board	All but $148 a day for 61st-90th days/benefit period
Misc. Hospital Services. & Supplies, such as. Drugs, X-Rays, Lab. Tests & Operating Room	All but $296 a day for 91st-150th days (if individual chooses to use 60 nonrenewable lifetime reserve days)
BLOOD	Pays all costs except nonreplacement fees (blood deductible) for first 3 pints in each benefit period
SKILLED NURSING FACILITY CARE	100% of costs for 1st 20 days (after a 3 day prior hospital confinement)/benefit period
	All but $74.00 a day for 21st-100th days/benefit period
	Beyond 100 days- Nothing/benefit period
MEDICARE PART B SERVICES AND SUPPLIES	80% of allowable charges (after $75 deductible/calendar year)
PRESCRIPTION DRUGS	Inpatient prescription drugs. 80% of allowable charges for immunosuppressive drugs during the first year following a covered transplant (after $75 deductible/calendar year)
BLOOD	80% of costs except nonreplacement fees (blood deductible) for first 3 pints (after $75 deductible/calendar year)

[Any other policy benefits not mentioned in this chart should be added to the chart in the order prescribed by the outline of coverage. If there are corresponding Medicare benefits, they should be shown.]

[Describe any coverage provisions changing due to Medicare modifications.]

[Include information about when premium adjustments that may be necessary due to changes in Medicare benefits will be effective.]

This chart summarizing the changes in your Medicare benefits and in your Medicare supplement provided by [Company] only briefly describes such benefits. For information on your Medicare benefits contact your Social Security Office or the Health Care Financing Administration. For information on your Medicare supplement Policy contact:

[Company or for an individual policy-name of agent] [Address/phone number]

6.	Statement that the policy does or does not cover the following: (A) Private duty nursing; (B) Skilled nursing home care costs (beyond what is covered by Medicare); (C) Custodial nursing home care costs; (D) Intermediate nursing home care costs; (E) Home health care above number of visits covered by Medicare; (F) Physician charges (above Medicare's reasonable charges); (G) Drugs (other than prescription drugs furnished during a hospital or skilled nursing facility stay); (H) Care received outside the U.S.A.; (I) Dental care or dentures, checkups, routine immunizations, cosmetic surgery, routine foot care, examinations for the cost of eyeglasses or hearing aids.
7.	A description of any policy provisions which exclude, eliminate, resist, reduce, limit, delay, or in any other manner operate to qualify payments of the benefits described in 4 above, including conspicuous statements;
	(a)	That the chart summarizing Medicare benefits only briefly describes such benefits.
	(b)	That the Health Care Financing Administration or its Medicare publications should be consulted for further details and limitations.
8.	A description of policy provisions respecting renewability or continuation of coverage, including any reservation of rights to change premium.
9.	The amount of premium for this policy. [Note: The term "certificate" should be substituted for the word "policy" throughout the outline of coverage where appropriate.]

Conn. Agencies Regs. § 38a-495-10

Effective September 25, 1992