Section 687B.225 - Minimum standards for coverage: Policy or certificate advertised, solicited or issued for delivery before July 16, 19921. A policy of insurance or subscriber contract must not be advertised, solicited or issued for delivery in this State as a policy or certificate to supplement Medicare before July 16, 1992, if it fails to meet the standards established by this section. These are minimum standards and do not preclude the inclusion of other provisions or benefits that are not inconsistent with these standards.2. A policy to supplement Medicare or a certificate issued for delivery in this State before July 16, 1992, must not:(a) Deny a claim for losses incurred more than 6 months after the effective date of coverage for a preexisting condition.(b) Define a preexisting condition more restrictively than as 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.(c) Indemnify against any loss resulting from sickness on a different basis than for a loss resulting from an accident.3. A policy to supplement Medicare or a certificate must 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 such changes.4. A "noncancellable," "guaranteed renewable" or "noncancellable and guaranteed renewable" policy must not:(a) 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 premiums; or(b) Be cancelled or denied renewal by the insurer solely on the grounds of deterioration of health.5. Termination of a policy to supplement Medicare or of a certificate must 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 predicated upon the continuous total disability of the insured, limited to the duration of the policy benefit period, if any, or to payment of the maximum benefits.6. A policy to supplement Medicare that is subject to the minimum standards adopted pursuant to the Medicare Catastrophic Coverage Act of 1988, Public Law 100-360, 102 Stat. 683, July 1, 1988, must provide at least the following benefits: (a) Coverage of Medicare Part A eligible expenses for hospitalization to the extent not covered by Medicare from the 61st day through the 90th day in any Medicare benefit period.(b) Coverage for either all or none of the Medicare Part A inpatient hospital deductible amount.(c) Coverage of Medicare Part A eligible expenses incurred as daily hospital charges during use of Medicare's lifetime hospital inpatient reserve days.(d) Upon exhaustion of all Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 90 percent of all Medicare Part A eligible expenses for hospitalization that are not covered by Medicare, subject to a lifetime maximum benefit of an additional 365 days.(e) Coverage under Medicare Part A for the reasonable cost of the first 3 pints of blood, or an equivalent quantity of packed red blood cells, as defined by federal regulations, unless replaced in accordance with federal regulations or already paid for pursuant to Part B. Plans K and L provide for 50 percent and 75 percent coverage of the cost, respectively.(f) Coverage for the coinsurance amount, or, for services from a hospital outpatient department paid under a prospective payment system, the copayment amount, of Medicare eligible expenses under Part B regardless of hospital confinement, subject to a maximum calendar year out-of-pocket amount that is equal to the Medicare Part B deductible.(g) Coverage under Medicare Part B for the reasonable cost of the first 3 pints of blood, or equivalent quantities of packed red blood cells, as defined by federal regulations, unless replaced in accordance with federal regulations or already paid for pursuant to Part A, subject to the Medicare deductible amount. Plans K and L provide for 50 percent and 75 percent coverage of the cost, respectively.7. For the purposes of this section:(a) "Medicare eligible expenses" means expenses for health care of the kind covered by Medicare, to the extent recognized as reasonable by Medicare. Payment of benefits by an insurer for such expenses may be conditioned upon the same or less restrictive conditions of payment, including determinations of medical necessity, as are applicable to Medicare claims.(b) "Policy to supplement Medicare" means a group or individual policy of accident and sickness insurance, or a subscriber contract of one or more hospital and medical service associations or health maintenance organizations, that is advertised, marketed or designed primarily as a supplement to the reimbursement provided under Medicare for the hospital, medical or surgical expenses of one or more persons eligible for Medicare by reason of age.Nev. Admin. Code § 687B.225
Added to NAC by Comm'r of Insurance, 2-21-89, eff. 3-15-89; A 11-16-90; 7-16-92; 8-2-94; R075-02, 9-20-2002; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit; A by Comm'r of Insurance by R066-07, 1-30-2008; R049-09, 10-27-2009