N.J. Admin. Code § 11:4-23.6

Current through Register Vol. 56, No. 21, November 4, 2024

Section 11:4-23.6 - General minimum benefit standards for all Medicare supplement policies and certificates

(a) No policy or certificate shall be advertised, solicited, or issued for delivery in this State as a Medicare supplement policy if it does not meet the minimum standards contained in this section.

(b) The following general standards apply to Medicare supplement policies and certificates and are in addition to all other requirements of this subchapter.

1. A Medicare supplement policy or certificate shall not exclude or limit benefits for losses incurred as a result of a preexisting condition after six months from the effective date of coverage, nor shall a preexisting condition be defined more restrictively than as set forth at 11:4-23.4(a)9.

2. A Medicare supplement policy or certificate shall not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents.

3. A Medicare supplement policy or certificate shall 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 correspondingly modified subject to the requirements of 11:4-23.1 1.

4. A Medicare supplement policy or certificate shall not:

i. Provide for termination of coverage of an eligible spouse because of termination of coverage of the insured other than for nonpayment of premium; or

ii. Provide for termination of a covered persons' coverage by the carrier solely on the grounds of age or deterioration of health.

5. Termination of a Medicare supplement policy or certificate shall be without prejudice to any continuous loss which commenced while the policy or certificate 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 covered person limited to the duration of the policy benefit period, if any, or payment of the maximum benefits. Receipt of Medicare Part D benefits will not be considered in determining continuous loss.

6. Existing Medicare supplement policies and certificates shall be appropriately amended or endorsed to eliminate benefit duplications with Medicare which are caused by Medicare benefit changes. Any riders or endorsements shall specify the benefits deleted, or shall otherwise result in a clear description of the Medicare supplement benefits provided by the policy. Such riders or endorsements shall be submitted for filing by the Commissioner.

7. If a Medicare supplement policy eliminates an outpatient prescription drug benefit as a result of requirements imposed by the Medicare Prescription Drug, Improvement and Modernization Act of 2003, Pub. L. 108-173, the modified policy shall be deemed to satisfy the guaranteed renewal requirements of this subchapter.

(c) A carrier shall neither cancel nor nonrenew a Medicare supplement policy or certificate for any reason other than nonpayment of premium or material misrepresentation. With respect to terminations of group policies, or membership in a group, the following standards shall apply:

1. If a group policyholder terminates the group Medicare supplement policy without replacing that policy as provided in (c)3 below, the carrier shall offer individuals covered under group policies at least the following two coverage choices:

i. An individual guaranteed renewable Medicare supplement policy which provides for continuation of the benefits contained in the group policy; and

ii. An individual Medicare supplement policy which provides only benefits that otherwise are required to meet 11:4-23.8 if offered with an effective date for coverage prior to June 1, 2010 and 11:4-23.8A(d) if offered with an effective date for coverage on or after June 1, 2010.

2. If membership in a group is terminated, the carrier shall:

i. Offer the individual whose membership is terminated the conversion opportunities described in (c)1 above; or

ii. Offer the individual whose membership is terminated continuation of coverage under the group policy, but only at the option of the group policyholder.

3. If a group policyholder replaces one group Medicare supplement policy by another group Medicare supplement policy, the carrier issuing the replacement coverage shall offer coverage to all persons who were covered under the old group policy on its date of termination. Coverage under the new group policy shall not result in any exclusions for preexisting conditions that would have been covered under the group policy which was replaced.

N.J. Admin. Code § 11:4-23.6

Amended by R.1988 d.587, effective 12/19/1988 (operative January 1, 1989).
See: 20 N.J.R. 2510(a), 20 N.J.R. 3155(c).
Added (b)6.-10.; (c)1 and renumbered (c)1.-4. as i.-iv.; added (c)2.
Amended by R.1991 d.121, effective 3/4/1991.
See: 22 N.J.R. 771(a), 23 N.J.R. 690(c).
In (b)7: revised internal references to chapter.
Amended by R.1991 d.345, effective 7/1/1991.
See: 23 N.J.R. 1264(a), 23 N.J.R. 2014(a).
Deleted "group insurance", "For individual or group subscriber contract may", "which"; added "shall", "if it" in (a).
Added "nor shall a preexisting condition be defined more restrictively than as set forth at N.J.A.C. 11:4-23.4(a)11." in (b) with stylistic change.
Added "in response to which premiums may be correspondingly modified subject to the requirements of N.J.A.C. 11:4-23.8" in (b)3.
Deleted ", or subscriber" in (b)4i.
Deleted "For hospital or medical service corporation" in (b)4ii.
Deleted (b)6, 7, 9, 10.
Recodified existing (b)8 as 6; deleted "commissioner for filing with 45 days after the effective dates of Medicare benefit changes".
Added (c) and (d).
Recodified existing (c) as (e); recodified existing (c)1i, ii, iii, iv as (e)2, 3, 4, 6.
Deleted "For policies issued prior to January 1, 1989;"; added "coverage for either all or none of the Medicare Part A in-patient hospital deductible amount;" in recodified (e)1.
Added (e)5, 7.
Deleted "of $ 200.00 of such expenses and to a maximum calendar year benefit of at least $ 5,000."; added "regardless of hospital confinement", "amount equal to the Medicare Part B" in recodified (e)6.
Deleted (c)2.
Amended by R.1993 d.26, effective 1/4/1993.
See: 24 N.J.R. 12(a), 25 N.J.R. 141(a).
General standards for policies and certificates delineated, references to insurer changed to "carrier."
Amended by R.1996 d.295, effective 7/1/1996.
See: 28 N.J.R. 1647(a), 28 N.J.R. 3462(a).
Amended by R.2005 d.291, effective 9/6/2005.
See: 37 N.J.R. 1428(a), 37 N.J.R. 3376(a).
In (b), added the last sentence in 5, added 7.
Amended by R.2009 d.239, effective 8/3/2009.
See: 41 N.J.R. 956(a), 41 N.J.R. 2928(a).
Section was "General minimum benefit standards". In (b)3, substituted a comma for "amounts and" preceding "copayment", and substituted ", or coinsurance amounts. Premiums" for "percentage factors, if any, in response to which premiums"; and in (c)1ii, inserted "if offered with an effective date for coverage prior to June 1, 2010 and N.J.A.C. 11:4-23.8A(d) if offered with an effective date for coverage on or after June 1, 2010".