Section 69O-156.0086 - Standard Medicare Supplement Benefit Plans for 2020 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery to Newly Eligible Medicare Beneficiaries with an Effective Date for Coverage on or After January 1, 2020No policy or certificate that provides coverage of the Medicare Part B deductible may be advertised, solicited, delivered or issued for delivery in this state as a Medicare supplement policy or certificate to Newly Eligible Medicare Beneficiary. In accordance with the Medicare Access and CHIP Reauthorization Act of 2015 (Pub. L. No. 114-10, 129 Stat. 87 (2015)), all policies must comply with the following benefit standards:
(1) Benefit Requirements. The standards and requirements of this rule apply to all Medicare supplement policies or certificates delivered or issued for delivery to Newly Eligible Medicare Beneficiary. Standardized Medicare supplement benefit Plans C, F, and F with High Deductible, as defined in paragraphs 69O-156.0085(5)(c), (e), and (f), F.A.C., may not be offered to Newly Eligible Medicare Beneficiaries.(2) An issuer shall make available to each prospective policyholder and certificateholder a policy form or certificate form containing the basic (core) benefits, as defined in paragraph (6)(a).(3) If an issuer makes available any of the additional benefits described in paragraphs (6)(b)-(i), then the issuer shall make available to each prospective policyholder and certificateholder, in addition to a policy form or certificate form with only the basic (core) benefits as described in subsection (2) above, a policy form or certificate form containing either standardized Medicare supplement benefit Plan D as described in paragraph (6)(c) or standardized Medicare supplement benefit Plan G as described in paragraph (6)(d).(4) Applicability to Certain Individuals. This rule applies only to Newly Eligible Medicare Beneficiaries who are enrolled in Medicare Part B:(a) By reason of attaining age 65 on or after January 1, 2020; or(b) By reason of entitlement to benefits under Part A pursuant to sections 226(b) or 226A of the Social Security Act (42 U.S.C. §§ 426(b), 426-1) or who are deemed to be eligible for benefits under section 226(a) of the Social Security Act on or after January 1, 2020.(5)(a) Benefit plans shall conform in structure, language, designation, and format to the standard benefit plans listed in this subsection (6) and the definitions in Rule 69O-156.003, F.A.C., and must include a copy of Form OIR-B2-MSC2, Outline of Coverage, Benefit Plans, Benefit Chart of Medicare Supplement Plans Sold on or after January 1, 2020, effective 01/20.(6) Make-up of 2020 Standardized Benefit Plans:(a) Standardized Medicare supplement benefit Plan A shall include only the following: 1. 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.2. Coverage of Part A Medicare eligible expenses incurred for hospitalization to the extent not covered by Medicare for each Medicare lifetime inpatient reserve day used.3. Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of one hundred percent (100%) of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system (PPS) rate, or other appropriate Medicare standard of payment, subject to a lifetime maximum benefit of an additional 365 days. The provider shall accept the issuer's payment as payment in full and may not bill the insured for any balance.4. 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.5. Coverage for the coinsurance amount, or in the case of hospital outpatient department services paid under a prospective payment system, the co-payment amount, of Medicare eligible expenses under Part B regardless of hospital confinement, subject to the Medicare Part B deductible.6. Hospice Care: Coverage of cost sharing for all Part A Medicare eligible hospice care and respite care expenses.7. Home Health Care (Parts A & B) Medicare Approved Services: Medically necessary skilled care services and medical supplies.(b) Standardized Medicare supplement benefit Plan B shall include only the following: The basic (core) benefit as defined in paragraph (6)(a), plus one hundred percent (100%) of the Medicare Part A deductible amount per benefit period.(c) Standardized Medicare supplement benefit Plan D shall include only the following: The basic (core) benefit, as defined in paragraph (6)(a), plus one hundred percent (100%) of the Medicare Part A 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; and Medically Necessary Emergency Care in a Foreign Country, which is Coverage to the extent not covered by Medicare for eighty percent (80%) of the billed charges for Medicare-eligible expenses for medically necessary emergency hospital, physician, and medical care received in a foreign country, if such care would have been covered by Medicare if provided in the United States and if such care began during the first sixty (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.(d) Standardized Medicare supplement [regular] Plan G shall include only the following: The basic (core) benefit as defined in paragraph (6)(a), plus one hundred percent (100%) of the Medicare Part A 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; one hundred percent (100%) of the Medicare Part B excess charges and Medically Necessary Emergency Care in a Foreign Country, which is Coverage to the extent not covered by Medicare for eighty percent (80%) of the billed charges for Medicare-eligible expenses for medically necessary emergency hospital, physician and medical care received in a foreign country, if such care would have been covered by Medicare if provided in the United States and if such care began during the first sixty (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.(e) Standardized Medicare supplement Plan G With High Deductible shall include only the following: one hundred percent (100%) of covered expenses following the payment of the annual deductible set forth in subparagraph 2. below.1. The basic (core) benefit and additional benefits as defined in paragraph (6)(d).2. The annual deductible in standardized Medicare supplement Plan G With High Deductible shall consist of out-of-pocket expenses, other than premiums, for services covered by standardized Medicare supplement [regular] Plan G. The basis for the deductible shall be $2,240 and shall be adjusted annually from 2018 by the Secretary of the U.S. Department of Health and Human Services to reflect the change in the Consumer Price Index for all urban consumers for the twelve-month period ending with August of the preceding year, rounded to the nearest multiple of ten dollars ($10).(f) Standardized Medicare supplement Plan K shall include only the following: 1. Part A Hospital Coinsurance 61st through 90th days: Coverage of one hundred percent (100%) of the Part A hospital coinsurance amount for each day used from the 61st through the 90th day in any Medicare benefit period.2. Part A Hospital Coinsurance, 91st through 150th days: Coverage of one hundred percent (100%) of the Part A hospital coinsurance amount for each Medicare lifetime inpatient reserve day used from the 91st through the 150th day in any Medicare benefit period.3. Part A Hospitalization After 150 Days: Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of one hundred percent (100%) of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system (PPS) rate, or other appropriate Medicare standard of payment, subject to a lifetime maximum benefit of an additional 365 days. The provider shall accept the issuer's payment as payment in full and may not bill the insured for any balance.4. Medicare Part A Deductible: Coverage for fifty percent (50%) of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in subparagraph 11.5. Skilled Nursing Facility Care: Coverage for fifty percent (50%) of the coinsurance amount for each day used from the 21st day through the 100th day in a Medicare benefit period for post-hospital skilled nursing facility care eligible under Medicare Part A until the out-of-pocket limitation is met as described in subparagraph 11.6. Hospice Care: Coverage for fifty percent (50%) of cost sharing for all Part A Medicare eligible expenses and respite care until the out-of-pocket limitation is met as described in subparagraph 11.7. Blood: Coverage for fifty percent (50%), under Medicare Part A or B, of the reasonable cost of the first three (3) pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulations) until the out-of-pocket limitation is met as described in subparagraph 11.8. Home Health Care (Parts A & B) Medicare Approved Services: Coverage for fifty percent (50%) of medically necessary skilled care services and medical supplies.9. Part B Cost Sharing: Coverage for fifty percent (50%) of the cost sharing otherwise applicable under Medicare Part B after the policyholder pays the Part B deductible until the out-of-pocket limitation is met as described in subparagraph 11.10. Part B Preventive Services: Coverage of one hundred percent (100%) of the cost sharing for Medicare Part B preventive services after the policyholder pays the Part B deductible.11. Cost Sharing After Out-of-Pocket Limits: Coverage of one hundred percent (100%) of all cost sharing under Medicare Parts A and B for the balance of the calendar year after the individual has reached the out-of-pocket limitation on annual expenditures under Medicare Parts A and B. The basis for the out-of-pocket limitation shall be $5,240 and shall be adjusted annually from 2018 by the Secretary of the U.S. Department of Health and Human Services to reflect the appropriate inflation adjustment.(g) Standardized Medicare supplement Plan L shall include only the following: 1. Part A Hospital Coinsurance 61st through 90th days: Coverage of one hundred percent (100%) of the Part A hospital coinsurance amount for each day used from the 61st through the 90th day in any Medicare benefit period;2. Part A Hospital Coinsurance, 91st through 150th days: Coverage of one hundred percent (100%) of the Part A hospital coinsurance amount for each Medicare lifetime inpatient reserve day used from the 91st through the 150th day in any Medicare benefit period.3. Part A Hospitalization After 150 Days: Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of one hundred percent (100%) of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system (PPS) rate, or other appropriate Medicare standard of payment, subject to a lifetime maximum benefit of an additional 365 days. The provider shall accept the issuer's payment as payment in full and may not bill the insured for any balance.4. Medicare Part A Deductible: Coverage for seventy-five percent (75%) of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in subparagraph 11.5. Skilled Nursing Facility Care: Coverage for seventy-five percent (75%) of the coinsurance amount for each day used from the 21st day through the 100th day in a Medicare benefit period for post-hospital skilled nursing facility care eligible under Medicare Part A until the out-of-pocket limitation is met as described in subparagraph 11;6. Hospice Care: Coverage for seventy-five percent (75%) of cost sharing for all Part A Medicare eligible expenses and respite care until the out-of-pocket limitation is met as described in subparagraph 11.7. Blood: Coverage for seventy-five percent (75%), under Medicare Part A or B, of the reasonable cost of the first three (3) pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulations) until the out-of-pocket limitation is met as described in subparagraph 11.8. Home Health Care (Parts A & B) Medicare Approved Services: Coverage for seventy-five percent (75%) of medically necessary skilled care services and medical supplies.9. Part B Cost Sharing: Coverage for seventy-five percent (75%) of the cost sharing otherwise applicable under Medicare Part B after the policyholder pays the Part B deductible until the out-of-pocket limitation is met as described in subparagraph 11.10. Part B Preventive Services: Coverage of one hundred percent (100%) of the cost sharing for Medicare Part B preventive services after the policyholder pays the Part B deductible.11. Cost Sharing After Out-of-Pocket Limits: Coverage of one hundred percent (100%) of all cost sharing under Medicare Parts A and B for the balance of the calendar year after the individual has reached the out-of-pocket limitation on annual expenditures under Medicare Parts A and B. The basis for the out-of-pocket limitation shall be $5,240 and shall be adjusted annually from 2018 by the Secretary of the U.S. Department of Health and Human Services to reflect the appropriate inflation adjustment.(h) Standardized Medicare supplement Plan M shall include only the following: The basic (core) benefit as defined in paragraph (6)(a), plus fifty percent (50%) of the Medicare Part A 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; and Medically Necessary Emergency Care in a Foreign Country, which is Coverage to the extent not covered by Medicare for eighty percent (80%) of the billed charges for Medicare-eligible expenses for medically necessary emergency hospital, physician and medical care received in a foreign country, if such care would have been covered by Medicare if provided in the United States and if such care began during the first sixty (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.(i) Standardized Medicare supplement Plan N shall include only the following: The basic (core) benefit as defined in paragraph (6)(a), plus one hundred percent (100%) of the Medicare Part A 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; and Medically Necessary Emergency Care in a Foreign Country, which is Coverage to the extent not covered by Medicare for eighty percent (80%) of the billed charges for Medicare-eligible expenses for medically necessary emergency hospital, physician and medical care received in a foreign country, if such care would have been covered by Medicare if provided in the United States and if such care began during the first sixty (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; and Part B coverage with co-payments in the following amounts:1. The lesser of twenty dollars ($20) or the Medicare Part B coinsurance or co-payment for each covered health care provider office visit (including visits to medical specialists).2. The lesser of fifty dollars ($50) or the Medicare Part B coinsurance or co-payment for each covered emergency room visit, however, this co-payment shall be waived if the insured is admitted to any hospital and the emergency visit is subsequently covered as a Medicare Part A expense. For purposes of this subsection, "emergency care" shall mean care needed immediately because of an injury or an illness of sudden and unexpected onset.
(7) New or Innovative Benefits: An issuer may, with the prior written approval of the Office, offer policies or certificates with new or innovative benefits, in addition to the standardized benefits provided in a policy or certificate that otherwise complies with the applicable standards. The new or innovative benefits shall include only benefits that are appropriate to Medicare supplement insurance, are new or innovative, are not otherwise available, and are cost-effective. Approval of new or innovative benefits must not adversely impact the goal of Medicare supplement simplification. New or innovative benefits shall not include an outpatient prescription drug benefit. New or innovative benefits shall not be used to change or reduce benefits, including a change of any cost-sharing provision, in any standardized plan. Benefit plan standards applicable to Medicare supplement policies and certificates issued to individuals who are not a Newly Eligible Medicare Beneficiary remain subject to the requirements of Rules 69O-156.0075 and 69O-156.0085, F.A.C.
Fla. Admin. Code Ann. R. 69O-156.0086
Rulemaking Authority 624.308(1), 627.674(2) FS. Law Implemented 624.307(1), 627.410, 627.674, 627.6741 FS.
Adopted by Florida Register Volume 45, Number 238, December 10, 2019 effective 12/26/2019.