14 Va. Admin. Code § 5-150-50

Current through Register Vol. 40, No. 22, June 17, 2024

Section 14VAC5-150-50 - Benefit conversion requirements

A. Effective 60 days after enactment of federal law mandating Medicare benefit changes, no Medicare supplement insurance policy, contract, or certificate subject to this chapter, in effect on the effective date of this chapter (14VAC5-150-10 et seq.) shall contain benefits which duplicate benefits provided by Medicare.

B. General requirements.

1. On the later of:

a. Thirty days prior to the effective date of Medicare benefit changes, or

b. Sixty days after enactment of federal law mandating Medicare benefit changes,

every insurer, health services plan, health maintenance organization or other entity providing Medicare supplement insurance or benefits shall notify its policyholders, contract holders, and certificate holders of modifications it has made to Medicare supplement insurance policies or contracts. Such notice shall be in a format prescribed in Exhibit A and be written in outline form in clear and simple terms so as to facilitate comprehension. Such notice shall not contain or be accompanied by any solicitation.

2. No modifications to an existing Medicare supplement contract or policy shall be made at the time of or in connection with the notice requirements of this chapter except to the extent necessary to eliminate duplication of Medicare benefits and any modifications necessary under the policy or contract to provide indexed benefit adjustment.

3. As soon as practicable, but no longer than 60 days after the effective date of the Medicare benefit changes, every insurer, health services plan, health maintenance organization or other entity providing Medicare supplement insurance or contracts in this Commonwealth shall file with the Commission, in accordance with the applicable filing procedures of this Commonwealth:

a. Appropriate premium adjustments necessary to produce loss ratios as originally anticipated for the applicable policies or contracts. Such supporting documents as necessary to justify the adjustment shall accompany the filing.

b. Any appropriate riders, endorsements, or policy forms needed to accomplish the Medicare supplement insurance modifications necessary to eliminate benefit duplications with Medicare. Any such riders, endorsements, or policy forms shall provide a clear description of the medicare supplement benefits provided by the policy or contract.

4. Upon satisfying the filing and approval requirements of this Commonwealth, every insurer, health services plan, health maintenance organization or other entity providing Medicare supplement insurance shall provide each covered person with any rider, endorsement or policy form necessary to eliminate any benefit duplications under the policy or contract with benefits provided by Medicare.

5. No insurer, health services plan, health maintenance organization or other entity shall require any person covered under a Medicare supplement policy or contract which was in effect on August 31, 1988, to purchase additional coverage under such policy or contract unless such additional coverage was provided for in the policy contract.

6. Every insurer, health services plan, health maintenance organization or other entity providing Medicare supplement insurance shall make such premium adjustments as are necessary to produce an expected loss ratio under such policy or contract as will conform with minimum loss ratio standards for Medicare supplement policies and which is expected to result in a loss ratio at least as great as that originally anticipated by the insurer, health services plan, health maintenance organization or other entity for such medicare supplement insurance policies or contracts. No premium adjustment which would modify the loss ratio experience under the policy other than the adjustments described herein should be made with respect to a policy at any time other than upon its renewal date. Premium adjustments shall be in the form of refunds or premium credits and shall be made no later than upon renewal if credit is given, or within 60 days of the renewal date if a refund is provided to the premium payor.

14 Va. Admin. Code § 5-150-50

Derived from Regulation 32, Case No. INS870293, § 6, eff. August 31, 1988.

Statutory Authority

§§ 38.2-223, 38.2-3516 through 38.2-3520, 38.2-3600 through 38.2-3607 and 38.2-514 of the Code of Virginia.