Md. Code Regs. 31.10.06.28

Current through Register Vol. 51, No. 22, November 1, 2024

Section 31.10.06.28 - Standard Medicare Supplement Benefit Plans for 2010 Plans

A. Definitions.

(1) In this regulation, the following term has the meaning indicated.

(2) Term Defined. "Structure, language, and format" means style, arrangement, and overall content of a benefit.

B. General Standards.

(1) 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.

(2) 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.

(3) 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.

C. 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.

D. 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:

(1) A policy form or certificate form with only the core benefits as described in §C of this regulation; and

(2) 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.

E. 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.

F. Structure of Benefits.

(1) 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.

(2) 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.

G. 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.

H. Make-up of 2010 Standardized Benefit Plans.

(1) Standardized Medicare supplement benefit Plan A shall include only the following: The core benefits as defined in Regulation .27C of this chapter.

(2) 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.

(3) 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.

(4) 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.

(5) 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.

(6) Standardized Medicare Supplement Benefit Plan F With High Deductible.

(a) 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.

(b) 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.

(c) Annual Deductible.

(i) 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.

(ii) The basis for the deductible is $1,500.

(iii) 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.

(7) Standardized Medicare Supplement Benefit Plan G.

(a) 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.

(b) 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.

(8) Standardized Medicare Supplement Benefit Plan K.

(a) Plan K is mandated by the Medicare Prescription Drug, Improvement and Modernization Act of 2003.

(b) Plan K shall include only the following:

(i) 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;

(ii) 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;

(iii) 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;

(iv) 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;

(v) 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;

(vi) 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;

(vii) 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;

(viii) 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;

(ix) 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

(x) 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.

(c) 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.

(9) Standardized Medicare Supplement Benefit Plan L.

(a) Plan L is mandated by The Medicare Prescription Drug, Improvement and Modernization Act of 2003.

(b) Plan L shall include only the following:

(i) The benefits described in §H(8)(b)(i)-(iii) and (ix) of this regulation;

(ii) The benefit described in §H(8)(b)(iv)-(viii) of this regulation, but substituting 75 percent for 50 percent; and

(iii) The benefit described in §H(8)(b)(x) of this regulation, but substituting $2,000 for $4,000.

(10) 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.

(11) Standardized Medicare Supplement Benefit Plan N.

(a) 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:

(i) 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

(ii) The lesser of $50 or the Medicare Part B coinsurance or copayment for each covered emergency room visit.

(b) 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.

I. New or Innovative Benefits.

(1) 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.

(2) 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.

(3) Approval of new or innovative benefits may not adversely impact the goal of Medicare supplement simplification.

(4) New or innovative benefits may not include an outpatient prescription drug benefit.

(5) 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.

Md. Code Regs. 31.10.06.28

Regulations .28 adopted effective September 21, 2009 (36:19 Md. R. 1439)
Regulation .28H amended effective November 29, 2010 (37:24 Md. R. 1660); amended effective 46:1 Md. R. 13, eff. 1/14/2019