14 Va. Admin. Code § 5-160-50

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

Section 14VAC5-160-50 - Benefit conversion requirements

A. Effective January 1, 1990, no Medicare supplement insurance policy, contract or certificate in force in this Commonwealth shall contain benefits which duplicate benefits provided by Medicare.

B. Benefits eliminated by operation of the Medicare Catastrophic Coverage Act of 1988 ( Public Law 100-360, 102 Stat. 683 (July 1, 1988) 42 USC § 1305 ) transition provisions shall be restored.

C. For Medicare supplement policies subject to the minimum standards adopted by the states pursuant to Medicare Catastrophic Coverage Act of 1988, the minimum benefits shall be:

1. Coverage of Part A Medicare eligible expenses for hospitalization to the extent not covered by Medicare from the 61st day through the 90th day in any Medicare benefit period;

2. Coverage for either all or none of the Medicare Part A inpatient hospital deductible amount;

3. Coverage of Part A Medicare eligible expenses incurred as daily hospital charges during use of Medicare's lifetime hospital inpatient reserve days;

4. Upon exhaustion of all Medicare hospital inpatient coverage including the lifetime reserve days, coverage of 90% of all Medicare Part A eligible expenses for hospitalization not covered by Medicare subject to a lifetime maximum benefit of an additional 365 days;

5. Coverage under Medicare Part A for the reasonable cost of the first three (3) pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulations) unless replaced in accordance with federal regulations or already paid for under Part B.

6. Coverage for the coinsurance amount of Medicare eligible expenses under Part B regardless of hospital confinement, subject to a maximum calendar year out-of-pocket amount equal to the Medicare Part B deductible of $75;

7. Effective January 1, 1990, coverage under Medicare Part B for 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 or already paid for under Part A, subject to the Medicare deductible amount.

D. General requirements:

1. No later than January 31, 1990, every insurer, health services plan or other entity providing Medicare supplement insurance or benefits to a resident of this Commonwealth 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 the format adopted by the National Association of Insurance Commissioners (Appendix A).

a. Such notice shall include a description of revisions to the Medicare program and a description of each modification made to the coverage provided under the Medicare supplement insurance policy or contract.

b. The notice shall inform each covered person as to when any premium adjustment due to changes in Medicare benefits will be effective.

c. The notice of benefit modifications and any premium adjustments shall be in outline form and in clear and simple terms so as to facilitate comprehension.

d. 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 section except to the extent necessary to accomplish the purposes articulated in 14VAC5-160-10.

14 Va. Admin. Code § 5-160-50

Derived from Regulation 36, Case No. INS900003, § 6, eff. January 31, 1990.

Statutory Authority

§§ 38.2-223, 38.2-3516 through 38.2-3520, 38.2-3600 through 38.2-3609, 38.2-4214, 38.2-4215 and 38.2-514 of the Code of Virginia.