W. Va. Code R. § 114-24-7

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 114-24-7 - Standard Medicare Supplement Benefit Plans 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or After August 5, 1991 and with an Effective Date for Coverage Prior to June 1, 2010

7.1. 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 subsection 6.3 of this rule.

7.2. No groups, packages or combinations of Medicare supplement benefits other than those listed in this section shall be offered for sale in this state, except as may be permitted in subsection 7.7 of this section and in section 8 of this rule.

7.3. Benefit plans shall be uniform in structure, language, designation and format to the standard benefit plans "A" through "L" listed in this subsection and conform to the definitions in section 2 of this rule. Each benefit shall be structured in accordance with the format provided in subsections 6.3 and 6.4 or 6.5 of this rule and list the benefits in the order shown in this subsection. For purposes of this section, "structure, language, and format" means style, arrangement and overall content of a benefit.

7.4. An issuer may use, in addition to the benefit plan designations required in subsection 7.3 of this section, other designations to the extent permitted by law.

7.5. Make-up of benefit plans:

7.5.a. Standardized Medicare supplement benefit plan "A" shall be limited to the basic core benefits common to all benefit plans, as defined in subsection 6.3 of this rule.

7.5.b. Standardized Medicare supplement benefit plan "B" shall include only the following: The core benefit as defined in subsection 6.3 of this rule, plus the Medicare Part A deductible as defined in subdivision a, subsection 6.4 of this rule.

7.5.c. Standardized Medicare supplement benefit plan "C" shall include only the following: The core benefit as defined in subsection 6.3 of this rule, plus the Medicare Part A deductible, skilled nursing facility care, Medicare Part B deductible and medically necessary emergency care in a foreign country as defined in subdivisions a, b, c and h of subsection 6.4, respectively, of this rule.

7.5.d. Standardized Medicare supplement benefit plan "D" shall include only the following: The core benefit as defined in subsection 6.3 of this rule, plus the Medicare Part A deductible, skilled nursing facility care, medically necessary emergency care in a foreign country and the at-home recovery benefit as defined in subdivisions a, b, h and j of subsection 6.4, respectively, of this rule.

7.5.e. Standardized Medicare supplement benefit plan "E" shall include only the following: The core benefit as defined in subsection 6.3 of this rule, plus the Medicare Part A deductible, skilled nursing facility care, medically necessary emergency care in a foreign country and preventive medical care as defined in subdivisions a, b, h and i of subsection 6.4, respectively, of this rule.

7.5.f. Standardized Medicare supplement benefit plan "F" shall include only the following: The core benefit as defined in subsection 6.3 of this rule, plus the Medicare Part A deductible, the skilled nursing facility care, the Part B deductible, one hundred percent (100%) of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in subdivisions a, b, c, e and h of subsection 6.4, respectively, of this rule.

7.5.g. Standardized Medicare supplement benefit high deductible plan "F" shall include only the following: one hundred percent (100%) of covered expenses following the payment of the annual high deductible plan "F" deductible. The covered expenses include the core benefit as defined in subsection 6.3 of this rule, plus the Medicare Part A deductible, skilled nursing facility care, the Medicare Part B deductible, one hundred percent (100%) of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in subdivisions a, b, c, e, and h of subsection 6.4, respectively, of this rule. The annual high deductible plan "F" deductible shall consist of out-of-pocket expenses, other than premiums, for services covered by the Medicare supplement plan "F" policy, and shall be in addition to any other specific benefit deductibles. The annual high deductible plan "F" deductible shall be one thousand five hundred dollars ($1,500) for 1998 and 1999, and shall be based on the calendar year. It shall be adjusted annually thereafter by the Secretary 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 ten dollars ($10).

7.5.h. Standardized Medicare supplement benefit plan "G" shall include only the following: The core benefit as defined in subsection 6.3 of this rule, plus the Medicare Part A deductible, skilled nursing facility care, eighty percent (80%) of the Medicare Part B excess charges, medically necessary emergency care in a foreign country, and the at-home recovery benefit as defined in subdivisions a, b, d, h and j of subsection 6.4, respectively, of this rule.

7.5.i. Standardized Medicare supplement benefit plan "H" shall consist of only the following: The core benefit as defined in subsection 6.3 of this rule, plus the Medicare Part A deductible, skilled nursing facility care, basic prescription drug benefit, and medically necessary emergency care in a foreign country as defined in subdivisions a, b, f and h of subsection 6.4, respectively, of this rule. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005.

7.5.j. Standardized Medicare supplement benefit plan "I" shall consist of only the following: The core benefit as defined in subsection 6.3 of this rule, plus the Medicare Part A deductible, skilled nursing facility care, one hundred percent (100%) of the Medicare Part B excess charges, basic prescription drug benefit, medically necessary emergency care in a foreign country and at-home recovery benefit as defined in subdivisions a, b, e, f, h and j of subsection 6.4, respectively, of this rule. The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005.

7.5.k. Standardized Medicare supplement benefit plan "J" shall consist of only the following: The core benefit as defined in subsection 6.3 of this rule, plus the Medicare Part A deductible, skilled nursing facility care, Medicare Part B deductible, one hundred percent (100%) of the Medicare Part B excess charges, extended prescription drug benefit, medically necessary emergency care in a foreign country, preventive medical care and at-home recovery benefit as defined in subdivisions a, b, c, e, g, h, i and j of subsection 6.4, respectively, of this rule. The outpatient drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005.

7.5.l Standardized Medicare supplement benefit high deductible plan "J" shall consist of only the following: one hundred percent (100%) of covered expenses following the payment of the annual high deductible plan "J" deductible. The covered expenses include the core benefit as defined in subsection 6.3 of this rule, plus the Medicare Part A deductible, skilled nursing facility care, Medicare Part B deductible, one hundred percent (100%) of the Medicare Part B excess charges, extended prescription drug benefit, medically necessary emergency care in a foreign country, preventive medical care benefit and at-home recovery benefit as defined in subdivisions a, b, c, e, g, h, i and j of subsection 6.4, respectively, of this rule. The annual high deductible plan "J" deductible shall consist of out-of-pocket expenses, other than premiums, for services covered by the Medicare supplement plan "J" policy, and shall be in addition to any other specific benefit deductibles. The annual deductible shall be one thousand five hundred dollars ($1,500) for 1998 and 1999, and shall be based on a calendar year. It shall be adjusted annually thereafter by the Secretary 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 ten dollars ($10). The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005.

7.6. Make-up of two Medicare supplement plans mandated by The Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA);

7.6.a. Standardized Medicare supplement benefit plan "K" shall consist of only those benefits described in subdivision a, subsection 6.5 of this rule.

7.6.b. Standardized Medicare supplement benefit plan "L" shall consist of only those benefits described in subdivision b, subsection 6.5 of this rule.

7.7. New and Innovative Benefits: An issuer may, with the prior approval of the Commissioner, offer policies or certificates with new or innovative benefits in addition to the benefits provided in a policy or certificate that otherwise complies with the applicable standards. The new or innovative benefits may include benefits that are appropriate to Medicare supplement insurance, new or innovative, not otherwise available, cost-effective, and offered in a manner which is consistent with the goal of simplification of Medicare supplement policies. After December 31, 2005, the innovative benefit shall not include an outpatient prescription drug benefit.

W. Va. Code R. § 114-24-7