Or. Admin. Code § 836-052-0141

Current through Register Vol. 63, No. 10, October 1, 2024

Section 836-052-0141 - Standard Medicare Supplement Benefit Plans for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates with an Effective Date of Coverage on or After June 1, 2010

The following standards 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. No policy or certificate may be advertised, solicited, delivered, or issued for delivery in this state as a Medicare supplement policy or certificate unless it complies with these benefit standards. No issuer may offer any 1990 Standardized Medicare supplement benefit plan for sale with an effective date for coverage on or after June 1, 2010. Benefit standards applicable to Medicare supplement policies and certificates with an effective date for coverage before June 1, 2010 remain subject to the requirements of OAR 836-052-0133.

(1)

(a) 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 OAR 836-052-0132(2).

(b) If an issuer makes available any of the additional benefits described in OAR 836-052-0132(3) or offers standardized benefit Plans K or L as described subsections (5)(h) and (i) of this rule, then the issuer shall make available to each prospective policyholder and certificate holder, in addition to a policy form or certificate form with only the basic core benefits as described in subsection (a) of this section, a policy form or certificate form containing either standardized benefit Plan C as described in subsection (5)(c) of this rule or standardized benefit Plan F as described in subsection (5)(e) of this.

(2) No groups, packages or combinations of Medicare supplement benefits other than those listed in this rule shall be offered for sale in this state, except as may be permitted in subsection (6) of this rule and OAR 836-052-0139.

(3) Benefit plans shall be uniform in structure, language, designation and format to the standard benefit plans listed in this rule and conform to the definitions in OAR 836-052-0119. Each benefit plan must be structured in accordance with the format provided in 836-052-0132(2) and (3); or, in the case of plans K or L, in subsections (5)(h) and (i) of this rule and list the benefits in the order shown. For purposes of this rule, "structure, language, and format" means style, arrangement and overall content of a benefit.

(4) In addition to the benefit plan designations required in section (3) of this rule, an issuer may use other designations to the extent permitted by law.

(5) The content of the 2010 Standardized Medicare supplement benefit plans must be as follows:

(a) Standardized Medicare supplement benefit Plan A shall include only the basic core benefits as defined in OAR 836-052-0132 (2).

(b) Standardized Medicare supplement benefit Plan B shall include only the following: The basic core benefit as defined in OAR 836-052-0132(2); plus 100 percent of the Medicare Part A deductible as defined in 836-052-0132(3)(a).

(c) Standardized Medicare supplement benefit Plan C shall include only the following: The basic (core) benefit as defined OAR 836-052-0132(2); 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, each as defined in OAR 836-052-0132(3)(a), (c), (d) and (f).

(d) Standardized Medicare supplement benefit Plan D shall include only the following: The basic core benefit as defined in OAR 836-052-0142(2), plus 100 percent of the Medicare Part A deductible skilled nursing facility care, and medically necessary emergency care in an foreign country each as defined in 836-052-0132(3)(a)(c) and (f).

(e) Standardized Medicare supplement regular Plan F shall include only the following: The basic core benefit as defined in OAR 836-052-0132(2), plus 100 percent of the Medicare Part A deductible, the 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 each as defined in 836-052-132(3)(a), (c), (d), (e) and (f).

(f) Standardized Medicare supplement Plan F with high deductible shall include only the following: 100 percent of covered expenses following the payment of the annual deductible set forth in paragraph (B) of this subsection.

(A) The basic core benefit as defined in OAR 836-052-0132(2), 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 each as defined in 836-052-0132(3)(a), (c), (d), (e) and (f).

(B) The annual deductible in Plan F with high deductible shall consist of out-of-pocket expenses, other than premiums, for services covered by the standardized Medicare supplement regular Plan F, and shall be in addition to any other specific benefit deductibles. The basis for the deductible shall be $1,500 and shall be adjusted annually from 1999 according to the method prescribed 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, and rounded to the nearest multiple of $10.

(g) Standardized Medicare supplement benefit Plan G shall include only the following: The basic core benefit as defined in OAR 836-052-0132(2) of this regulation, 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 each as defined in 836-052-0132(3)(a), (c), (e) and (f). Effective January 1, 2020, the standardized benefit plans described in OAR 836-052-0144(1)(d) (Redesignated Plan G High Deductible) may be offered to any individual who was eligible for Medicare prior to January 1, 2020.

(h) Standardized Medicare supplement Plan K is mandated by The Medicare Prescription Drug, Improvement and Modernization Act of 2003, and shall include only the following:

(A) 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;

(B) 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;

(C) 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. The provider shall accept the issuer's payment as payment in full and may not bill the insured for any balance;

(D) 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 paragraph (J) of this subsection;

(E) 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 paragraph (J) of this subsection;

(F) 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 paragraph (J) of this subsection;

(G) Blood: Coverage for 50 percent under Medicare Part A or B, of the reasonable cost of the first three 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 paragraph (J) of this subsection;

(H) Except for coverage provided in paragraph (I) of this subsection, 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 paragraph (J) of this subsection;

(I) Coverage of 100 percent of the cost sharing for Medicare Part B preventive services after the policyholder pays the Part B deductible; and

(J) 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 $4000 in 2006, indexed each year by the appropriate inflation adjustment specified by the Secretary of the U.S. Department of Health and Human Services.

(i) Standardized Medicare supplement Plan L is mandated by The Medicare Prescription Drug, Improvement and Modernization Act of 2003, and shall include only the following:

(A) The benefits described in section (5)(h)(A)(B)(C) and (I) of this rule;

(B) The benefit described in section (5) (h)(D)(E)(F)(G) and (H) of this rule, but substituting 75 percent for 50 percent; and

(C) The benefit described in section (5)(h)(J) of this rule, but substituting $2000 for $4000.

(j) Standardized Medicare supplement Plan M shall include only the following: The basic core benefit as defined in OAR 836-052-0132(2), plus 50 percent of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country each as defined in 836-052-0132(3)(b), (c) and (f).

(k) Standardized Medicare supplement Plan N shall include only the following: The basic core benefit as defined in OAR 836-052-0132(2), plus 100 percent of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country each as defined in 836-052-0132(3)(a), (c) and (f), with copayments in the following amounts:

(A) 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

(B) The lesser of $50 or the Medicare Part B coinsurance or copayment for each covered emergency room visit; however, this copayment shall be waived if the insured is admitted to any hospital and the emergency visit is subsequently covered as a Medicare Part A expense.

(6) With the prior approval of the Director of the Department of Consumer and Business Services, an issuer may 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.

Or. Admin. Code § 836-052-0141

ID 3-2009, f. 6-30-09, cert. ef. 7-1-09; ID 30-2018, amend filed 08/28/2018, effective 9/1/2018

Statutory/Other Authority: ORS 743.683

Statutes/Other Implemented: ORS 743.010 & 743.683