10192.1. All Medicare supplement policies and certificates shall
comply with the provisions of subdivision (b) of Section 10291.5 and
Chapter 7 (commencing with Section 10600) of Part 2 of Division 2,
regardless of the situs of the contract.
10192.2. The purpose of this article is to provide for the
reasonable standardization of coverage and simplification of terms
and benefits of Medicare supplement policies, to facilitate public
understanding and comparison of those policies, to eliminate
provisions contained in those policies that may be misleading or
confusing in connection with the purchase of the policies or with the
settlement of claims, and to provide for full disclosures in the
sale of Medicare supplement insurance policies to persons eligible
for Medicare.
10192.3. (a) Except as otherwise provided in this section or in
Sections 10192.7, 10192.12, 10192.13, 10192.16, and 10192.21, this
article shall apply to all Medicare supplement policies advertised,
solicited, or issued for delivery in this state on or after January
1, 2001, and to all certificates delivered in this state under a
group Medicare supplement master policy agreement that have been
advertised, solicited, or issued for delivery in this state on or
after that date.
(b) This article shall not apply to a policy or contract of one or
more employers or labor organizations, or of the trustees of a fund
established by one or more employers or labor organizations, or
combination thereof, for employees or former employees, or a
combination thereof, or for members or former members, or a
combination thereof, of the labor organizations.
(c) This article shall not apply to Medicare supplement policies
subject to Article 3.5 (commencing with Section 1358.1) of Chapter
2.2 of Division 2 of the Health and Safety Code.
(d) The commissioner may, from time to time, promulgate
regulations to implement this article.
10192.4. The following definitions apply for the purposes of this
article:
(a) "Applicant" means:
(1) The person who seeks to contract for insurance benefits, in
the case of an individual Medicare supplement policy.
(2) The proposed certificate holder, in the case of a group
Medicare supplement policy.
(b) "Bankruptcy" means that situation in which a Medicare
Advantage organization that is not an issuer has filed, or has had
filed against it, a petition for declaration of bankruptcy and has
ceased doing business in the state.
(c) "Certificate" means a certificate issued for delivery in this
state under a group Medicare supplement policy.
(d) "Certificate form" means the form on which the certificate is
issued for delivery by the issuer.
(e) "Continuous period of creditable coverage" means the period
during which an individual was covered by creditable coverage, if
during the period of the coverage the individual had no breaks in
coverage greater than 63 days.
(f) (1) "Creditable coverage" means, with respect to an
individual, coverage of the individual provided under any of the
following:
(A) Any individual or group contract, policy, certificate, or
program that is written or administered by a health care service
plan, health insurer, fraternal benefits society, self-insured
employer plan, or any other entity, in this state or elsewhere, and
that arranges or provides medical, hospital, and surgical coverage
not designed to supplement other private or governmental plans. The
term includes continuation or conversion coverage.
(B) Part A or B of Title XVIII of the federal Social Security Act
(42 U.S.C. Sec. 1395c et seq.) (Medicare).
(C) Title XIX of the federal Social Security Act (42 U.S.C. Sec.
1396 et seq.) (Medicaid (known as Medi-Cal in California)), other
than coverage consisting solely of benefits under Section 1928 of
that act.
(D) Chapter 55 of Title 10 of the United States Code (CHAMPUS).
(E) A medical care program of the Indian Health Service or of a
tribal organization.
(F) A state health benefits risk pool.
(G) A health plan offered under Chapter 89 of Title 5 of the
United States Code (Federal Employees Health Benefits Program).
(H) A public health plan as defined in federal regulations
authorized by Section 2701(c)(1)(I) of the federal Public Health
Service Act, as amended by Public Law 104-191, the federal Health
Insurance Portability and Accountability Act of 1996.
(I) A health benefit plan under Section 5(e) of the federal Peace
Corps Act (Section 2504(e) of Title 22 of the United States Code).
(J) Any other publicly sponsored program, provided in this state
or elsewhere, of medical, hospital, and surgical care.
(K) Any other creditable coverage as defined by subsection (c) of
Section 2701 of Title XXVII of the federal Public Health Service Act
(42 U.S.C. Sec. 300gg(c)).
(2) "Creditable coverage" shall not include one or more, or any
combination of, the following:
(A) Coverage only for accident or disability income insurance, or
any combination thereof.
(B) Coverage issued as a supplement to liability insurance.
(C) Liability insurance, including general liability insurance and
automobile liability insurance.
(D) Workers' compensation or similar insurance.
(E) Automobile medical payment insurance.
(F) Credit-only insurance.
(G) Coverage for onsite medical clinics.
(H) Other similar insurance coverage, specified in federal
regulations, under which benefits for medical care are secondary or
incidental to other insurance benefits.
(3) "Creditable coverage" shall not include the following benefits
if they are provided under a separate policy, certificate, or
contract of insurance or are otherwise not an integral part of the
plan:
(A) Limited scope dental or vision benefits.
(B) Benefits for long-term care, nursing home care, home health
care, community-based care, or any combination thereof.
(C) Other similar, limited benefits as are specified in federal
regulations.
(4) "Creditable coverage" shall not include the following benefits
if offered as independent, noncoordinated benefits:
(A) Coverage only for a specified disease or illness.
(B) Hospital indemnity or other fixed indemnity insurance.
(5) "Creditable coverage" shall not include the following if
offered as a separate policy, certificate, or contract of insurance:
(A) Medicare supplemental health insurance as defined under
Section 1882(g)(1) of the federal Social Security Act.
(B) Coverage supplemental to the coverage provided under Chapter
55 of Title 10 of the United States Code.
(C) Similar supplemental coverage provided to coverage under a
group health plan.
(g) "Employee welfare benefit plan" means a plan, fund, or program
of employee benefits as defined in Section 1002 of Title 29 of the
United States Code (Employee Retirement Income Security Act).
(h) "Insolvency" means when an issuer, licensed to transact the
business of insurance in this state, has had a final order of
liquidation entered against it with a finding of insolvency by a
court of competent jurisdiction in the issuer's state of domicile.
(i) "Issuer" includes insurance companies, fraternal benefit
societies, and any other entity delivering, or issuing for delivery,
Medicare supplement policies or certificates in this state, except
entities subject to Article 3.5 (commencing with Section 1358.1) of
Chapter 2.2 of Division 2 of the Health and Safety Code.
(j) "Medi-Cal" means California's version of Medicaid under Title
XIX of the federal Social Security Act.
(k) "Medicare" means the Health Insurance for the Aged Act, Title
XVIII of the Social Security Amendments of 1965, as amended.
(l) "Medicare Advantage plan" means a plan of coverage for health
benefits under Medicare Part C and includes:
(1) Coordinated care plans that provide health care services,
including, but not limited to, health care service plans (with or
without a point-of-service option), plans offered by
provider-sponsored organizations, and preferred provider
organizations plans.
(2) Medical savings account plans coupled with a contribution into
a Medicare Advantage medical savings account.
(3) Medicare Advantage private fee-for-service plans.
(m) "Medicare supplement policy" means a group or individual
policy of health insurance, other than a policy issued pursuant to a
contract under Section 1876 of the federal Social Security Act (42
U.S.C. Sec. 1395mm) or an issued policy under a demonstration project
specified in Section 1395ss(g)(1) of Title 42 of the United States
Code, that is advertised, marketed, or designed primarily as a
supplement to reimbursements under Medicare for the hospital,
medical, or surgical expenses of persons eligible for Medicare.
"Medicare supplement policy" does not include a Medicare Advantage
plan established under Medicare Part C, an outpatient prescription
drug plan established under Medicare Part D, or a health care
prepayment plan that provides benefits pursuant to an agreement under
subparagraph (A) of paragraph (1) of subsection (a) of Section 1833
of the federal Social Security Act.
(n) "Policy form" means the form on which the policy is issued for
delivery by the issuer.
(o) "1990 standardized Medicare supplement benefit plan," "1990
standardized benefit plan," or "1990 plan" means a group or
individual policy of Medicare supplement insurance issued on or after
July 21, 1992, and with an effective date prior to June 1, 2010, and
includes Medicare supplement insurance policies and certificates
renewed on or after that date which are not replaced by the issuer at
the request of the insured.
(p) "2010 standardized Medicare supplement benefit plan," "2010
standardized benefit plan," or "2010 plan" means a group or
individual policy of Medicare supplement insurance issued with an
effective date on or after June 1, 2010.
(q) "Secretary" means the Secretary of the United States
Department of Health and Human Services.
10192.5. A policy or certificate shall not be advertised,
solicited, or issued for delivery as a Medicare supplement policy or
certificate unless the policy or certificate contains definitions or
terms that conform to the requirements of this section.
(a) (1) "Accident," "accidental injury," or "accidental means"
shall be defined to employ "result" language and shall not include
words that establish an accidental means test or use words such as
"external, violent, visible wounds" or other similar words of
description or characterization.
(2) The definition shall not be more restrictive than the
following: "injury or injuries for which benefits are provided means
accidental bodily injury sustained by the insured person that is the
direct result of an accident, independent of disease or bodily
infirmity or any other cause, and occurs while insurance coverage is
in force."
(3) The definition may provide that injuries shall not include
injuries for which benefits are provided or available under any
workers' compensation, employer's liability, or similar law, unless
prohibited by law.
(b) "Benefit period" or "Medicare benefit period" shall not be
defined more restrictively than as defined in the Medicare Program.
(c) "Convalescent nursing home," "extended care facility," or
"skilled nursing facility" shall not be defined more restrictively
than as defined in the Medicare Program.
(d) (1) "Health care expenses" means expenses of health
maintenance organizations associated with the delivery of health care
services, which expenses are analogous to incurred losses of
insurers.
(2) "Health care expenses" shall not include any of the following:
(A) Home office and overhead costs.
(B) Advertising costs.
(C) Commissions and other acquisition costs.
(D) Taxes.
(E) Capital costs.
(F) Administrative costs.
(G) Claims processing costs.
(e) "Hospital" may be defined in relation to its status,
facilities, and available services or to reflect its accreditation by
the Joint Commission on Accreditation of Hospitals, but not more
restrictively than as defined in the Medicare Program.
(f) "Medicare" shall be defined in the policy and certificate.
"Medicare" may be substantially defined as "The Health Insurance for
the Aged Act, Title XVIII of the Social Security Amendments of 1965,
as amended," or "Title I, Part I of Public Law 89-97, as enacted by
the 89th Congress and popularly known as the Health Insurance for the
Aged Act, as amended," or words of similar import.
(g) "Medicare eligible expenses" shall mean expenses of the kinds
covered by Medicare Parts A and B, to the extent recognized as
reasonable and medically necessary by Medicare.
(h) "Physician" shall not be defined more restrictively than as
defined in the Medicare Program.
(i) (1) "Sickness" shall not be defined more restrictively than as
follows: "sickness means illness or disease of an insured person
that first manifests itself after the effective date of insurance and
while the insurance is in force."
(2) The definition may be further modified to exclude sicknesses
or diseases for which benefits are provided under any workers'
compensation, occupational disease, employer's liability, or similar
law.
10192.55. (a) With regard to Medicare supplement policies, all
insurers, brokers, agents, and others engaged in the business of
insurance owe a policyholder or a prospective policyholder a duty of
honesty, and a duty of good faith and fair dealing.
(b) Conduct of an insurer, broker, or agent during the offer and
sale of a Medicare supplement policy previous to the purchase is
relevant to any action alleging a breach of the duty of honesty, and
a duty of good faith and fair dealing set forth in subdivision (a).
10192.6. (a) Except for permitted preexisting condition clauses as
described in Sections 10192.7, 10192.8, and 10192.81, a policy or
certificate shall not be advertised, solicited, or issued for
delivery as a Medicare supplement policy if the policy or certificate
contains limitations or exclusions on coverage that are more
restrictive than those of Medicare.
(b) A Medicare supplement policy or certificate shall not use
waivers to exclude, limit, or reduce coverage or benefits for
specifically named or described preexisting diseases or physical
conditions.
(c) A Medicare supplement policy or certificate in force shall not
contain benefits that duplicate benefits provided by Medicare.
(d) (1) Subject to paragraphs (4) and (5) of subdivision (a) of
Section 10192.8, a Medicare supplement policy with benefits for
outpatient prescription drugs that was issued prior to January 1,
2006, shall be renewed for current policyholders, at the option of
the policyholder, who do not enroll in Medicare Part D.
(2) A Medicare supplement policy with benefits for outpatient
prescription drugs shall not be issued on and after January 1, 2006.
(3) On and after January 1, 2006, a Medicare supplement policy
with benefits for outpatient prescription drugs shall not be renewed
after the policyholder enrolls in Medicare Part D unless both of the
following conditions exist:
(A) The policy is modified to eliminate outpatient prescription
drug coverage for outpatient prescription drug expenses incurred
after the effective date of the individual's coverage under a
Medicare Part D plan.
(B) The premium is adjusted to reflect the elimination of
outpatient prescription drug coverage at the time of enrollment in
Medicare Part D, accounting for any claims paid if applicable.
10192.7. A policy or certificate shall not be advertised,
solicited, or issued for delivery as a Medicare supplement policy or
certificate prior to January 1, 2001, unless it meets or exceeds
requirements applicable pursuant to this code that were in effect
prior to that date.
10192.8. The following standards are applicable to all Medicare
supplement policies or certificates advertised, solicited, or issued
for delivery on or after January 1, 2001, and with an effective date
prior to June 1, 2010. A policy or certificate shall not be
advertised, solicited, or issued for delivery as a Medicare
supplement policy or certificate unless it complies with these
benefit standards.
(a) The following general standards apply to Medicare supplement
policies and certificates and are in addition to all other
requirements of this article:
(1) A Medicare supplement policy or certificate shall not exclude
or limit benefits for losses incurred more than six months from the
effective date of coverage because it involved a preexisting
condition. The policy or certificate shall not define a preexisting
condition more restrictively than a condition for which medical
advice was given or treatment was recommended by or received from a
physician within six months before the effective date of coverage.
(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 modified to correspond with those changes.
(4) A Medicare supplement policy or certificate shall not provide
for termination of coverage of a spouse solely because of the
occurrence of an event specified for termination of coverage of the
insured, other than the nonpayment of premium.
(5) Each Medicare supplement policy shall be guaranteed renewable
or noncancelable.
(A) The issuer shall not cancel or nonrenew the policy solely on
the ground of health status of the individual.
(B) The issuer shall not cancel or nonrenew the policy for any
reason other than nonpayment of premium or misrepresentation which is
shown by the issuer to be material to the acceptance for coverage.
The contestability period for Medicare supplement insurance shall be
two years.
(C) If the Medicare supplement policy is terminated by the master
policyholder and is not replaced as provided under subparagraph (E),
the issuer shall offer certificate holders an individual Medicare
supplement policy that, at the option of the certificate holder,
either provides for continuation of the benefits contained in the
group policy or provides for benefits that otherwise meet the
requirements of one of the standardized policies defined in this
article.
(D) If an individual is a certificate holder in a group Medicare
supplement policy and membership in the group is terminated, the
issuer shall either offer the certificate holder the conversion
opportunity described in subparagraph (C) or, at the option of the
group policyholder, shall offer the certificate holder continuation
of coverage under the group policy.
(E) (i) If a group Medicare supplement policy is replaced by
another group Medicare supplement policy purchased by the same
policyholder, the issuer of the replacement policy shall offer
coverage to all persons covered under the old group policy on its
date of termination. Coverage under the new policy shall not result
in any exclusion for preexisting conditions that would have been
covered under the group policy being replaced.
(ii) If a Medicare supplement policy or certificate replaces
another Medicare supplement policy or certificate that has been in
force for six months or more, the replacing issuer shall not impose
an exclusion or limitation based on a preexisting condition. If the
original coverage has been in force for less than six months, the
replacing issuer shall waive any time period applicable to
preexisting conditions, waiting periods, elimination periods, or
probationary periods in the new policy or certificate to the extent
the time was spent under the original coverage.
(F) 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 (P.L. 108-173), the policy as modified as a result of that act
shall be deemed to satisfy the guaranteed renewal requirements of
this paragraph.
(6) Termination of a Medicare supplement policy or certificate
shall be without prejudice to any continuous loss that commenced
while the policy 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 insured, limited to the
duration of the policy benefit period, if any, or to payment of the
maximum benefits. Receipt of Medicare Part D benefits shall not be
considered in determining a continuous loss.
(7) (A) (i) A Medicare supplement policy or certificate shall
provide that benefits and premiums under the policy or certificate
shall be suspended at the request of the policyholder or certificate
holder for the period, not to exceed 24 months, in which the
policyholder or certificate holder has applied for and is determined
to be entitled to Medi-Cal, but only if the policyholder or
certificate holder notifies the issuer of the policy or certificate
within 90 days after the date the individual becomes entitled to
assistance. Upon receipt of timely notice, the insurer shall return
directly to the insured that portion of the premium attributable to
the period of Medi-Cal eligibility, subject to adjustment for paid
claims. If suspension occurs and if the policyholder or certificate
holder loses entitlement to Medi-Cal, the policy or certificate shall
be automatically reinstituted (effective as of the date of
termination of entitlement) as of the termination of entitlement if
the policyholder or certificate holder provides notice of loss of
entitlement within 90 days after the date of loss and pays the
premium attributable to the period, effective as of the date of
termination of entitlement, or equivalent coverage shall be provided
if the prior form is no longer available.
(ii) A Medicare supplement policy or certificate shall provide
that benefits and premiums under the policy or certificate shall be
suspended at the request of the policyholder or certificate holder
for any period that may be provided by federal regulation if the
policyholder is entitled to benefits under Section 226(b) of the
Social Security Act and is covered under a group health plan, as
defined in Section 1862(b)(1)(A)(v) of the Social Security Act. If
suspension occurs and the policyholder or certificate holder loses
coverage under the group health plan, the policy or certificate shall
be automatically reinstituted, effective as of the date of loss of
coverage if the policyholder provides notice within 90 days of the
date of the loss of coverage.
(B) Reinstitution of coverages:
(i) Shall not provide for any waiting period with respect to
treatment of preexisting conditions.
(ii) Shall provide for resumption of coverage that is
substantially equivalent to coverage in effect before the date of
suspension. If the suspended Medicare supplement policy provided
coverage for outpatient prescription drugs, reinstitution of the
policy for a Medicare Part D enrollee shall not include coverage for
outpatient prescription drugs but shall otherwise provide coverage
that is substantially equivalent to the coverage in effect before the
date of suspension.
(iii) Shall provide for classification of premiums on terms at
least as favorable to the policyholder or certificate holder as the
premium classification terms that would have applied to the
policyholder or certificate holder had the coverage not been
suspended.
(8) If an issuer makes a written offer to the Medicare supplement
policyholders or certificate holders of one or more of its plans, to
exchange during a specified period from his or her 1990 standardized
plan, as described in Section 10192.9, to a 2010 standardized plan,
as described in Section 10192.91, the offer and subsequent exchange
shall comply with the following requirements:
(A) An issuer need not provide justification to the commissioner
if the insured replaces a 1990 standardized policy or certificate
with an issue age rated 2010 standardized policy or certificate at
the insured's original issue age and duration. If an insured's policy
or certificate to be replaced is priced on an issue age rate
schedule at the time of that offer, the rate charged to the insured
for the new exchanged policy shall recognize the policy reserve
buildup, due to the prefunding inherent in the use of an issue age
rate basis, for the benefit of the insured. The method proposed to be
used by an issuer shall be filed with the commissioner.
(B) The rating class of the new policy or certificate shall be the
class closest to the insured's class of the replaced coverage.
(C) An issuer shall not apply new preexisting condition
limitations or a new incontestability period to the new policy for
those benefits contained in the exchanged 1990 standardized policy or
certificate of the insured, but may apply preexisting condition
limitations of no more than six months to any added benefits
contained in the new 2010 standardized policy or certificate not
contained in the exchanged policy. This subparagraph shall not apply
to an applicant who is guaranteed issue under Section 10192.11 or
10192.12.
(D) The new policy or certificate shall be offered to all
policyholders or certificate holders within a given plan, except
where the offer or issue would be in violation of state or federal
law.
(9) A Medicare supplement policy shall not limit coverage
exclusively to a single disease or affliction.
(b) With respect to the standards for basic (core) benefits for
benefit plans A to J, inclusive, every issuer shall make available a
policy or certificate including only the following basic "core"
package of benefits to each prospective insured. An issuer may make
available to prospective insureds any of the other Medicare
supplement insurance benefit plans in addition to the basic core
package, but not in lieu of it. However, the benefits described in
paragraphs (6) and (7) shall not be offered so long as California is
required to disallow these benefits for Medicare beneficiaries by the
Centers for Medicare and Medicaid Services or other agent of the
federal government under Section 1395ss of Title 42 of the United
States Code.
(1) Coverage of Part A Medicare eligible expenses for
hospitalization to the extent not covered by Medicare from the 61st
day to the 90th day, inclusive, in any Medicare benefit period.
(2) Coverage of Part A Medicare eligible expenses incurred for
hospitalization to the extent not covered by Medicare for each
Medicare lifetime inpatient reserve day used.
(3) 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
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.
(4) Coverage under Medicare Parts A and 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.
(5) Coverage for the coinsurance amount, or in the case of
hospital outpatient department services, the copayment amount, of
Medicare eligible expenses under Part B regardless of hospital
confinement, subject to the Medicare Part B deductible.
(6) Coverage of the actual cost, up to the legally billed amount,
of an annual mammogram as provided in Section 10123.81, to the extent
not paid by Medicare.
(7) Coverage of the actual cost, up to the legally billed amount,
of an annual cervical cancer screening test as provided in Section
10123.18, to the extent not paid by Medicare.
(c) The following additional benefits shall be included in
Medicare supplement benefit plans B to J, inclusive, only as provided
by Section 10192.9.
(1) With respect to the Medicare Part A deductible, coverage for
all of the Medicare Part A inpatient hospital deductible amount per
benefit period.
(2) With respect to skilled nursing facility care, coverage for
the actual billed charges up to the coinsurance amount from the 21st
day to the 100th day, inclusive, in a Medicare benefit period for
posthospital skilled nursing facility care eligible under Medicare
Part A.
(3) With respect to the Medicare Part B deductible, coverage for
all of the Medicare Part B deductible amount per calendar year
regardless of hospital confinement.
(4) With respect to 80 percent of the Medicare Part B excess
charges, coverage for 80 percent of the difference between the actual
Medicare Part B charge as billed, not to exceed any charge
limitation established by the Medicare Program or state law, and the
Medicare-approved Part B charge. If the insurer limits payment to a
limiting charge, the insurer has the burden to establish that amount
as the legal limit.
(5) With respect to 100 percent of the Medicare Part B excess
charges, coverage for all of the difference between the actual
Medicare Part B charge as billed, not to exceed any charge limitation
established by the Medicare Program or state law, and the
Medicare-approved Part B charge. If the insurer limits payment to a
limiting charge, the insurer has the burden to establish that amount
as the legal limit.
(6) With respect to the basic outpatient prescription drug
benefit, coverage for 50 percent of outpatient prescription drug
charges, after a two hundred fifty dollar ($250) calendar year
deductible, to a maximum of one thousand two hundred fifty dollars
($1,250) in benefits received by the insured per calendar year, to
the extent not covered by Medicare. On and after January 1, 2006, no
Medicare supplement policy may be sold or issued if it includes a
prescription drug benefit.
(7) With respect to the extended outpatient prescription drug
benefit, coverage for 50 percent of outpatient prescription drug
charges, after a two hundred fifty dollar ($250) calendar year
deductible, to a maximum of three thousand dollars ($3,000) in
benefits received by the insured per calendar year, to the extent not
covered by Medicare. On and after January 1, 2006, no Medicare
supplement policy may be sold or issued if it includes a prescription
drug benefit.
(8) With respect to medically necessary emergency care in a
foreign country, coverage to the extent not covered by Medicare for
80 percent of the billed charges for Medicare-eligible expenses for
medically necessary emergency hospital, physician, and medical care
received in a foreign country, which care would have been covered by
Medicare if provided in the United States and which care began during
the first 60 consecutive days of each trip outside the United
States, subject to a calendar year deductible of two hundred fifty
dollars ($250), and a lifetime maximum benefit of fifty thousand
dollars ($50,000). For purposes of this benefit, "emergency care"
shall mean care needed immediately because of an injury or an illness
of sudden and unexpected onset.
(9) With respect to the following, reimbursement shall be for the
actual charges up to 100 percent of the Medicare-approved amount for
each service, as if Medicare were to cover the service as identified
in American Medical Association Current Procedural Terminology (AMA
CPT) codes, up to a maximum of one hundred twenty dollars ($120)
annually under this benefit, however, this benefit shall not include
payment for any procedure covered by Medicare:
(A) An annual clinical preventive medical history and physical
examination that may include tests and services from subparagraph (B)
and patient education to address preventive health care measures.
(B) The following screening tests or preventive services that are
not covered by Medicare, the selection and frequency of which are
determined to be medically appropriate by the attending physician:
(i) Fecal occult blood test.
(ii) Mammogram.
(C) Influenza vaccine administered at any appropriate time during
the year.
(10) With respect to the at-home recovery benefit, coverage for
the actual charges up to forty dollars ($40) per visit and an annual
maximum of one thousand six hundred dollars ($1,600) per year to
provide short-term, at-home assistance with activities of daily
living for those recovering from an illness, injury, or surgery.
(A) For purposes of this benefit, the following definitions shall
apply:
(i) "Activities of daily living" include, but are not limited to,
bathing, dressing, personal hygiene, transferring, eating,
ambulating, assistance with drugs that are normally
self-administered, and changing bandages or other dressings.
(ii) "Care provider" means a duly qualified or licensed home
health aide or homemaker, or a personal care aide or nurse provided
through a licensed home health care agency or referred by a licensed
referral agency or licensed nurses registry.
(iii) "Home" shall mean any place used by the insured as a place
of residence, provided that the place would qualify as a residence
for home health care services covered by Medicare. A hospital or
skilled nursing facility shall not be considered the insured's place
of residence.
(iv) "At-home recovery visit" means the period of a visit required
to provide at-home recovery care, without any limit on the duration
of the visit, except that each consecutive four hours in a 24-hour
period of services provided by a care provider is one visit.
(B) With respect to coverage requirements and limitations, the
following shall apply:
(i) At-home recovery services provided shall be primarily services
that assist in activities of daily living.
(ii) The insured's attending physician shall certify that the
specific type and frequency of at-home recovery services are
necessary because of a condition for which a home care plan of
treatment was approved by Medicare.
(iii) Coverage is limited to the following:
(I) No more than the number and type of at-home recovery visits
certified as necessary by the insured's attending physician. The
total number of at-home recovery visits shall not exceed the number
of Medicare-approved home health care visits under a
Medicare-approved home care plan of treatment.
(II) The actual charges for each visit up to a maximum
reimbursement of forty dollars ($40) per visit.
(III) One thousand six hundred dollars ($1,600) per calendar year.
(IV) Seven visits in any one week.
(V) Care furnished on a visiting basis in the insured's home.
(VI) Services provided by a care provider as defined in
subparagraph (A).
(VII) At-home recovery visits while the insured is covered under
the policy or certificate and not otherwise excluded.
(VIII) At-home recovery visits received during the period the
insured is receiving Medicare-approved home care services or no more
than eight weeks after the service date of the last Medicare-approved
home health care visit.
(C) Coverage is excluded for the following:
(i) Home care visits paid for by Medicare or other government
programs.
(ii) Care provided by family members, unpaid volunteers, or
providers who are not care providers.
(d) The standardized Medicare supplement benefit plan "K" shall
consist of the following benefits:
(1) Coverage of 100 percent of the Medicare Part A hospital
coinsurance amount for each day used from the 61st to the 90th day,
inclusive, in any Medicare benefit period.
(2) Coverage of 100 percent of the Medicare Part A hospital
coinsurance amount for each Medicare lifetime inpatient reserve day
used from the 91st to the 150th day, inclusive, in any Medicare
benefit period.
(3) 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 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 for this benefit as payment in full and shall not bill the
insured for any balance.
(4) With respect to the 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
described in paragraph (10) is met.
(5) With respect to skilled nursing facility care, coverage for 50
percent of the coinsurance amount for each day used from the 21st
day to the 100th day, inclusive, in a Medicare benefit period for
posthospital skilled nursing facility care eligible under Medicare
Part A until the out-of-pocket limitation described in paragraph (10)
is met.
(6) With respect to hospice care, coverage for 50 percent of cost
sharing for all Medicare Part A eligible expenses and respite care
until the out-of-pocket limitation described in paragraph (10) is
met.
(7) 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 described in paragraph (10) is
met.
(8) Except for coverage provided in paragraph (9), 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 (10).
(9) Coverage of 100 percent of the cost sharing for Medicare Part
B preventive services, after the policyholder pays the Medicare Part
B deductible.
(10) 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 four thousand dollars
($4,000) in 2006, indexed each year by the appropriate inflation
adjustment specified by the secretary.
(e) The standardized Medicare supplement benefit plan "L" shall
consist of the following benefits:
(1) The benefits described in paragraphs (1), (2), (3), and (9) of
subdivision (d).
(2) With respect to the Medicare Part A deductible, coverage for
75 percent of the Medicare Part A inpatient hospital deductible
amount per benefit period until the out-of-pocket limitation
described in paragraph (8) is met.
(3) With respect to skilled nursing facility care, coverage for 75
percent of the coinsurance amount for each day used from the 21st
day to the 100th day, inclusive, in a Medicare benefit period for
posthospital skilled nursing facility care eligible under Medicare
Part A until the out-of-pocket limitation described in paragraph (8)
is met.
(4) With respect to hospice care, coverage for 75 percent of cost
sharing for all Medicare Part A eligible expenses and respite care
until the out-of-pocket limitation described in paragraph (8) is met.
(5) Coverage for 75 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 described in paragraph (8) is met.
(6) Except for coverage provided in paragraph (7), coverage for 75
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 described in paragraph (8) is met.
(7) Coverage for 100 percent of the cost sharing for Medicare Part
B preventive services after the policyholder pays the Part B
deductible.
(8) Coverage of 100 percent of the cost sharing for 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 two thousand dollars ($2,000) in 2006,
indexed each year by the appropriate inflation adjustment specified
by the secretary.
(f) An issuer shall prominently indicate through text edits, or by
other means acceptable to the commissioner, an amendment made to a
Medicare supplement policy form that the department previously
approved on the basis that the amendment is consistent with this
section. The department may, in its discretion, restrict its review
to amendments made to Medicare supplement policy forms that have not
previously been found consistent with this section in order to
facilitate the availability of amended policy forms that are
consistent with the federal Medicare Modernization Act. The
department shall not restrict its review if the amendment makes
additional changes to the Medicare supplement policy form.
10192.81. The following standards are applicable to all Medicare
supplement policies or certificates delivered or issued for delivery
in this state with an effective date 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 on or after June 1, 2010.
Benefit standards applicable to Medicare supplement policies and
certificates issued with an effective date prior to June 1, 2010,
remain subject to the requirements of Section 10192.8.
(a) The following general standards apply to Medicare supplement
policies and certificates and are in addition to all other
requirements of this article:
(1) A Medicare supplement policy or certificate shall not exclude
or limit benefits for losses incurred more than six months from the
effective date of coverage because it involved a preexisting
condition. The policy or certificate shall not define a preexisting
condition more restrictively than a condition for which medical
advice was given or treatment was recommended by or received from a
physician within six months before the effective date of coverage.
(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 modified to correspond with those changes.
(4) A Medicare supplement policy or certificate shall not provide
for termination of coverage of a spouse solely because of the
occurrence of an event specified for termination of coverage of the
insured, other than the nonpayment of premium.
(5) Each Medicare supplement policy shall be guaranteed renewable.
(A) The issuer shall not cancel or nonrenew the policy solely on
the ground of health status of the individual.
(B) The issuer shall not cancel or nonrenew the policy for any
reason other than nonpayment of premium or material misrepresentation
which is shown by the issuer to be material to the acceptance for
coverage. The contestability period for Medicare supplement insurance
shall be two years, pursuant to Section 10350.2.
(C) If the Medicare supplement policy is terminated by the master
policyholder and is not replaced as provided under subparagraph (E),
the issuer shall offer certificate holders an individual Medicare
supplement policy which, at the option of the certificate holder,
does one of the following:
(i) Provides for continuation of the benefits contained in the
group policy.
(ii) Provides for benefits that otherwise meet the requirements of
one of the standardized policies defined in this article.
(D) If an individual is a certificate holder in a group Medicare
supplement policy and the individual terminates membership in the
group, the issuer shall do one of the following:
(i) Offer the certificate holder the conversion opportunity
described in subparagraph (C).
(ii) At the option of the group policyholder, offer the
certificate holder continuation of coverage under the group policy.
(E) (i) If a group Medicare supplement policy is replaced by
another group Medicare supplement policy purchased by the same
policyholder, the issuer of the replacement policy shall offer
coverage to all persons covered under the old group policy on its
date of termination. Coverage under the new policy shall not result
in any exclusion for preexisting conditions that would have been
covered under the group policy being replaced.
(ii) If a Medicare supplement policy or certificate replaces
another Medicare supplement policy or certificate that has been in
force for six months or more, the replacing issuer shall not impose
an exclusion or limitation based on a preexisting condition. If the
original coverage has been in force for less than six months, the
replacing issuer shall waive any time period applicable to
preexisting conditions, waiting periods, elimination periods, or
probationary periods in the new policy or certificate to the extent
the time was spent under the original coverage.
(6) Termination of a Medicare supplement policy or certificate
shall be without prejudice to any continuous loss that commenced
while the policy 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 insured, limited to the
duration of the policy benefit period, if any, or payment of the
maximum benefits. Receipt of Medicare Part D benefits shall not be
considered in determining a continuous loss.
(7) (A) (i) A Medicare supplement policy or certificate shall
provide that benefits and premiums under the policy or certificate
shall be suspended at the request of the policyholder or certificate
holder for the period, not to exceed 24 months, in which the
policyholder or certificate holder has applied for and is determined
to be entitled to medical assistance under Medi-Cal, but only if the
policyholder or certificate holder notifies the issuer of the policy
or certificate within 90 days after the date the individual becomes
entitled to assistance. Upon receipt of timely notice, the insurer
shall return directly to the insured that portion of the premium
attributable to the period of Medi-Cal eligibility, subject to
adjustment for paid claims.
(ii) If suspension occurs and if the policyholder or certificate
holder loses entitlement to medical assistance under Medi-Cal, the
policy or certificate shall be automatically reinstituted (effective
as of the date of termination of entitlement) as of the termination
of entitlement if the policyholder or certificate holder provides
notice of loss of entitlement within 90 days after the date of loss
and pays the premium attributable to the period, effective as of the
date of termination of entitlement or equivalent coverage shall be
provided if the prior form is no longer available.
(iii) Each Medicare supplement policy shall provide that benefits
and premiums under the policy shall be suspended (for any period that
may be provided by federal regulation) at the request of the
policyholder if the policyholder is entitled to benefits under
Section 226(b) of the federal Social Security Act and is covered
under a group health plan (as defined in Section 1862(b)(1)(A)(v) of
the federal Social Security Act). If suspension occurs and if the
policyholder or certificate holder loses coverage under the group
health plan, the policy shall be automatically reinstituted
(effective as of the date of loss of coverage) if the policyholder
provides notice of loss of coverage within 90 days after the date of
the loss and pays the applicable premium.
(B) Reinstitution of coverages shall comply with all of the
following requirements:
(i) Not provide for any waiting period with respect to treatment
of preexisting conditions.
(ii) Provide for resumption of coverage that is substantially
equivalent to coverage in effect before the date of suspension.
(iii) Provide for classification of premiums on terms at least as
favorable to the policyholder or certificate holder as the premium
classification terms that would have applied to the policyholder or
certificate holder had the coverage not been suspended.
(8) A Medicare supplement policy shall not limit coverage
exclusively to a single disease or affliction.
(9) A Medicare supplement policy shall provide an examination
period of 30 days after the receipt of the policy by the applicant
for purposes of review, during which time the applicant may return
the policy as described in subdivision (e) of Section 10192.17.
(b) With respect to the standards for basic (core) benefits for
benefit plans A, B, C, D, F, high deductible F, G, M, and N, every
issuer of Medicare supplement insurance benefit plans shall make
available a policy or certificate including only the following basic
"core" package of benefits to each prospective insured. An issuer may
make available to prospective insureds any of the other Medicare
Supplement Insurance Benefit Plans in addition to the basic (core)
package, but not in lieu of it. However, the benefits described in
paragraphs (7) and (8) shall not be offered so long as California is
required to disallow these benefits for Medicare beneficiaries by the
Centers for Medicare and Medicaid Services or other agent of the
federal government under Section 1395ss of Title 42 of the United
States Code.
(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, inclusive, in any Medicare benefit period.
(2) Coverage of Part A Medicare eligible expenses incurred for
hospitalization to the extent not covered by Medicare for each
Medicare lifetime inpatient reserve day used.
(3) 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.
(4) Coverage under Medicare Parts A and 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.
(5) Coverage for the coinsurance amount, or in the case of
hospital outpatient department services paid under a prospective
payment system, the copayment amount, of Medicare eligible expenses
under Part B regardless of hospital confinement, subject to the
Medicare Part B deductible.
(6) Coverage of cost sharing for all Part A Medicare eligible
hospice care and respite care expenses.
(7) Coverage of the actual cost, up to the legally billed amount,
of an annual mammogram as provided in Section 10123.81, to the extent
not paid by Medicare.
(8) Coverage of the actual cost, up to the legally billed amount,
of an annual cervical cancer screening test as provided in Section
10123.18, to the extent not paid by Medicare.
(c) The following additional benefits shall be included in
Medicare supplement benefit plans B, C, D, F, high deductible F, G,
M, and N, consistent with the plan type and benefits for each plan as
provided in Section 10192.91:
(1) With respect to the Medicare Part A deductible, coverage for
100 percent of the Medicare Part A inpatient hospital deductible
amount per benefit period.
(2) With respect to the Medicare Part A deductible, coverage for
50 percent of the Medicare Part A inpatient hospital deductible
amount per benefit period.
(3) With respect to skilled nursing facility care, coverage for
the actual billed charges up to the coinsurance amount from the 21st
day through the 100th day in a Medicare benefit period for
posthospital skilled nursing facility care eligible under Medicare
Part A.
(4) With respect to the Medicare Part B deductible, coverage for
100 percent of the Medicare Part B deductible amount per calendar
year regardless of hospital confinement.
(5) With respect to 100 percent of the Medicare Part B excess
charges, coverage for all of the difference between the actual
Medicare Part B charges as billed, not to exceed any charge
limitation established by the Medicare Program or state law, and the
Medicare-approved Part B charge.
(6) With respect to medically necessary emergency care in a
foreign country, coverage to the extent not covered by Medicare for
80 percent of the billed charges for Medicare-eligible expenses for
medically necessary emergency hospital, physician, and medical care
received in a foreign country, which care would have been covered by
Medicare if provided in the United States and which care began during
the first 60 consecutive days of each trip outside the United
States, subject to a calendar year deductible of two hundred fifty
dollars ($250), and a lifetime maximum benefit of fifty thousand
dollars ($50,000). For purposes of this benefit, "emergency care"
shall mean care needed immediately because of an injury or an illness
of sudden and unexpected onset.
10192.9. The following standards are applicable to all Medicare
supplement policies or certificates delivered or issued for delivery
in this state on or after July 1, 1992, and with an effective date
prior to June 1, 2010.
(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 subdivision
(b) of Section 10192.8.
(b) 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 by subdivision (f)
and by Section 10192.10.
(c) Benefit plans shall be uniform in structure, language,
designation and format to the standard benefit plans A to L,
inclusive, listed in subdivision (e), and shall conform to the
definitions in Section 10192.4. Each benefit shall be structured in
accordance with the format provided in subdivisions (b), (c), (d),
and (e) of Section 10192.8 and list the benefits in the order listed
in subdivision (e). For purposes of this section, "structure,
language, and format" means style, arrangement, and overall content
of a benefit.
(d) An issuer may use, in addition to the benefit plan
designations required in subdivision (c), other designations to the
extent permitted by law.
(e) With respect to the makeup of benefit plans, the following
shall apply:
(1) Standardized Medicare supplement benefit plan A shall be
limited to the basic (core) benefit common to all benefit plans, as
defined in subdivision (b) of Section 10192.8.
(2) Standardized Medicare supplement benefit plan B shall include
only the following: the core benefit, plus the Medicare Part A
deductible as defined in paragraph (1) of subdivision (c) of Section
10192.8.
(3) Standardized Medicare supplement benefit plan C shall include
only the following: the core benefit, 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 paragraphs (1), (2), (3), and (8) of
subdivision (c) of Section 10192.8, respectively.
(4) Standardized Medicare supplement benefit plan D shall include
only the following: the core benefit, 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 paragraphs (1), (2), (8), and (10) of subdivision (c)
of Section 10192.8, respectively.
(5) Standardized Medicare supplement benefit plan E shall include
only the following: the core benefit, 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 paragraphs (1), (2), (8), and (9) of subdivision (c) of
Section 10192.8, respectively.
(6) Standardized Medicare supplement benefit plan F shall include
only the following: the core benefit, plus the Medicare Part A
deductible, the skilled nursing facility care, the Medicare Part B
deductible, 100 percent of the Medicare Part B excess charges, and
medically necessary emergency care in a foreign country as defined in
paragraphs (1), (2), (3), (5), and (8) of subdivision (c) of Section
10192.8, respectively.
(7) Standardized Medicare supplement benefit high deductible plan
F shall include only the following: 100 percent of covered expenses
following the payment of the annual high deductible plan F
deductible. The covered expenses include the core benefit, plus the
Medicare Part A deductible, skilled nursing facility care, the
Medicare Part B deductible, 100 percent of the Medicare Part B excess
charges, and medically necessary emergency care in a foreign country
as defined in paragraphs (1), (2), (3), (5), and (8) of subdivision
(c) of Section 10192.8, respectively. 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, as adjusted annually thereafter
by the secretary to reflect the change in the Consumer Price Index
for all urban consumers for the 12-month period ending with August of
the preceding year, and rounded to the nearest multiple of ten
dollars ($10).
(8) Standardized Medicare supplement benefit plan G shall include
only the following: the core benefit, plus the Medicare Part A
deductible, skilled nursing facility care, 80 percent of the Medicare
Part B excess charges, medically necessary emergency care in a
foreign country, and the at-home recovery benefit as defined in
paragraphs (1), (2), (4), (8), and (10) of subdivision (c) of Section
10192.8, respectively.
(9) Standardized Medicare supplement benefit plan H shall consist
of only the following: the core benefit, plus the Medicare Part A
deductible, skilled nursing facility care, basic outpatient
prescription drug benefit, and medically necessary emergency care in
a foreign country as defined in paragraphs (1), (2), (6), and (8) of
subdivision (c) of Section 10192.8, respectively. The outpatient
prescription drug benefit shall not be included in a Medicare
supplement policy sold on or after January 1, 2006.
(10) Standardized Medicare supplement benefit plan I shall consist
of only the following: the core benefit, plus the Medicare Part A
deductible, skilled nursing facility care, 100 percent of the
Medicare Part B excess charges, basic outpatient prescription drug
benefit, medically necessary emergency care in a foreign country, and
at-home recovery benefit as defined in paragraphs (1), (2), (5),
(6), (8), and (10) of subdivision (c) of Section 10192.8,
respectively. The outpatient prescription drug benefit shall not be
included in a Medicare supplement policy sold on or after January 1,
2006.
(11) Standardized Medicare supplement benefit plan J shall consist
of only the following: the core benefit, plus the Medicare Part A
deductible, skilled nursing facility care, Medicare Part B
deductible, 100 percent of the Medicare Part B excess charges,
extended outpatient prescription drug benefit, medically necessary
emergency care in a foreign country, preventive medical care, and
at-home recovery benefit as defined in paragraphs (1), (2), (3), (5),
(7), (8), (9), and (10) of subdivision (c) of Section 10192.8,
respectively. The outpatient prescription drug benefit shall not be
included in a Medicare supplement policy sold on or after January 1,
2006.
(12) Standardized Medicare supplement benefit high deductible plan
J shall consist of only the following: 100 percent of covered
expenses following the payment of the annual high deductible plan J
deductible. The covered expenses include the core benefit, plus the
Medicare Part A deductible, skilled nursing facility care, Medicare
Part B deductible, 100 percent of the Medicare Part B excess charges,
extended outpatient prescription drug benefit, medically necessary
emergency care in a foreign country, preventive medical care benefit,
and at-home recovery benefit as defined in paragraphs (1), (2), (3),
(5), (7), (8), (9), and (10) of subdivision (c) of Section 10192.8,
respectively. 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, as adjusted
annually thereafter by the secretary to reflect the change in the
Consumer Price Index for all urban consumers for the 12-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 on
or after January 1, 2006.
(13) Standardized Medicare supplement benefit plan K shall consist
of only those benefits described in subdivision (d) of Section
10192.8.
(14) Standardized Medicare supplement benefit plan L shall consist
of only those benefits described in subdivision (e) of Section
10192.8.
(f) 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, that are not otherwise available and
that are cost-effective and offered in a manner that is consistent
with the goal of simplification of Medicare supplement policies. On
and after January 1, 2006, the innovative benefit shall not include
an outpatient prescription drug benefit.
10192.91. The following standards are applicable to all Medicare
supplement policies or certificates delivered or issued for delivery
in this state with an effective date 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 plan standards.
Benefit plan standards applicable to Medicare supplement policies and
certificates issued with an effective date before June 1, 2010,
remain subject to the requirements of Section 10192.9.
(a) (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 subdivision
(b) of Section 10192.81.
(2) If an issuer makes available any of the additional benefits
described in subdivision (c) of Section 10192.81, or offers
standardized benefit plans K or L, as described in paragraphs (8) and
(9) of subdivision (e), 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 paragraph (1), a policy form or certificate form
containing either standardized benefit plan C, as described in
paragraph (3) of subdivision (e), or standardized benefit plan F, as
described in paragraph (5) of subdivision (e).
(b) 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 subdivision (f)
and by Section 10192.10.
(c) Benefit plans shall be uniform in structure, language,
designation, and format to the standard benefit plans listed in
subdivision (e) and conform to the definitions in Section 10192.4.
Each benefit shall be structured in accordance with the format
provided in subdivisions (b) and (c) of Section 10192.81; or, in the
case of plan K or L, in paragraph (8) or (9) of subdivision (e) and
list the benefits in the order shown in subdivision (e). For purpose
10192.1. All Medicare supplement policies and certificates shall
comply with the provisions of subdivision (b) of Section 10291.5 and
Chapter 7 (commencing with Section 10600) of Part 2 of Division 2,
regardless of the situs of the contract.
10192.2. The purpose of this article is to provide for the
reasonable standardization of coverage and simplification of terms
and benefits of Medicare supplement policies, to facilitate public
understanding and comparison of those policies, to eliminate
provisions contained in those policies that may be misleading or
confusing in connection with the purchase of the policies or with the
settlement of claims, and to provide for full disclosures in the
sale of Medicare supplement insurance policies to persons eligible
for Medicare.
10192.3. (a) Except as otherwise provided in this section or in
Sections 10192.7, 10192.12, 10192.13, 10192.16, and 10192.21, this
article shall apply to all Medicare supplement policies advertised,
solicited, or issued for delivery in this state on or after January
1, 2001, and to all certificates delivered in this state under a
group Medicare supplement master policy agreement that have been
advertised, solicited, or issued for delivery in this state on or
after that date.
(b) This article shall not apply to a policy or contract of one or
more employers or labor organizations, or of the trustees of a fund
established by one or more employers or labor organizations, or
combination thereof, for employees or former employees, or a
combination thereof, or for members or former members, or a
combination thereof, of the labor organizations.
(c) This article shall not apply to Medicare supplement policies
subject to Article 3.5 (commencing with Section 1358.1) of Chapter
2.2 of Division 2 of the Health and Safety Code.
(d) The commissioner may, from time to time, promulgate
regulations to implement this article.
10192.4. The following definitions apply for the purposes of this
article:
(a) "Applicant" means:
(1) The person who seeks to contract for insurance benefits, in
the case of an individual Medicare supplement policy.
(2) The proposed certificate holder, in the case of a group
Medicare supplement policy.
(b) "Bankruptcy" means that situation in which a Medicare
Advantage organization that is not an issuer has filed, or has had
filed against it, a petition for declaration of bankruptcy and has
ceased doing business in the state.
(c) "Certificate" means a certificate issued for delivery in this
state under a group Medicare supplement policy.
(d) "Certificate form" means the form on which the certificate is
issued for delivery by the issuer.
(e) "Continuous period of creditable coverage" means the period
during which an individual was covered by creditable coverage, if
during the period of the coverage the individual had no breaks in
coverage greater than 63 days.
(f) (1) "Creditable coverage" means, with respect to an
individual, coverage of the individual provided under any of the
following:
(A) Any individual or group contract, policy, certificate, or
program that is written or administered by a health care service
plan, health insurer, fraternal benefits society, self-insured
employer plan, or any other entity, in this state or elsewhere, and
that arranges or provides medical, hospital, and surgical coverage
not designed to supplement other private or governmental plans. The
term includes continuation or conversion coverage.
(B) Part A or B of Title XVIII of the federal Social Security Act
(42 U.S.C. Sec. 1395c et seq.) (Medicare).
(C) Title XIX of the federal Social Security Act (42 U.S.C. Sec.
1396 et seq.) (Medicaid (known as Medi-Cal in California)), other
than coverage consisting solely of benefits under Section 1928 of
that act.
(D) Chapter 55 of Title 10 of the United States Code (CHAMPUS).
(E) A medical care program of the Indian Health Service or of a
tribal organization.
(F) A state health benefits risk pool.
(G) A health plan offered under Chapter 89 of Title 5 of the
United States Code (Federal Employees Health Benefits Program).
(H) A public health plan as defined in federal regulations
authorized by Section 2701(c)(1)(I) of the federal Public Health
Service Act, as amended by Public Law 104-191, the federal Health
Insurance Portability and Accountability Act of 1996.
(I) A health benefit plan under Section 5(e) of the federal Peace
Corps Act (Section 2504(e) of Title 22 of the United States Code).
(J) Any other publicly sponsored program, provided in this state
or elsewhere, of medical, hospital, and surgical care.
(K) Any other creditable coverage as defined by subsection (c) of
Section 2701 of Title XXVII of the federal Public Health Service Act
(42 U.S.C. Sec. 300gg(c)).
(2) "Creditable coverage" shall not include one or more, or any
combination of, the following:
(A) Coverage only for accident or disability income insurance, or
any combination thereof.
(B) Coverage issued as a supplement to liability insurance.
(C) Liability insurance, including general liability insurance and
automobile liability insurance.
(D) Workers' compensation or similar insurance.
(E) Automobile medical payment insurance.
(F) Credit-only insurance.
(G) Coverage for onsite medical clinics.
(H) Other similar insurance coverage, specified in federal
regulations, under which benefits for medical care are secondary or
incidental to other insurance benefits.
(3) "Creditable coverage" shall not include the following benefits
if they are provided under a separate policy, certificate, or
contract of insurance or are otherwise not an integral part of the
plan:
(A) Limited scope dental or vision benefits.
(B) Benefits for long-term care, nursing home care, home health
care, community-based care, or any combination thereof.
(C) Other similar, limited benefits as are specified in federal
regulations.
(4) "Creditable coverage" shall not include the following benefits
if offered as independent, noncoordinated benefits:
(A) Coverage only for a specified disease or illness.
(B) Hospital indemnity or other fixed indemnity insurance.
(5) "Creditable coverage" shall not include the following if
offered as a separate policy, certificate, or contract of insurance:
(A) Medicare supplemental health insurance as defined under
Section 1882(g)(1) of the federal Social Security Act.
(B) Coverage supplemental to the coverage provided under Chapter
55 of Title 10 of the United States Code.
(C) Similar supplemental coverage provided to coverage under a
group health plan.
(g) "Employee welfare benefit plan" means a plan, fund, or program
of employee benefits as defined in Section 1002 of Title 29 of the
United States Code (Employee Retirement Income Security Act).
(h) "Insolvency" means when an issuer, licensed to transact the
business of insurance in this state, has had a final order of
liquidation entered against it with a finding of insolvency by a
court of competent jurisdiction in the issuer's state of domicile.
(i) "Issuer" includes insurance companies, fraternal benefit
societies, and any other entity delivering, or issuing for delivery,
Medicare supplement policies or certificates in this state, except
entities subject to Article 3.5 (commencing with Section 1358.1) of
Chapter 2.2 of Division 2 of the Health and Safety Code.
(j) "Medi-Cal" means California's version of Medicaid under Title
XIX of the federal Social Security Act.
(k) "Medicare" means the Health Insurance for the Aged Act, Title
XVIII of the Social Security Amendments of 1965, as amended.
(l) "Medicare Advantage plan" means a plan of coverage for health
benefits under Medicare Part C and includes:
(1) Coordinated care plans that provide health care services,
including, but not limited to, health care service plans (with or
without a point-of-service option), plans offered by
provider-sponsored organizations, and preferred provider
organizations plans.
(2) Medical savings account plans coupled with a contribution into
a Medicare Advantage medical savings account.
(3) Medicare Advantage private fee-for-service plans.
(m) "Medicare supplement policy" means a group or individual
policy of health insurance, other than a policy issued pursuant to a
contract under Section 1876 of the federal Social Security Act (42
U.S.C. Sec. 1395mm) or an issued policy under a demonstration project
specified in Section 1395ss(g)(1) of Title 42 of the United States
Code, that is advertised, marketed, or designed primarily as a
supplement to reimbursements under Medicare for the hospital,
medical, or surgical expenses of persons eligible for Medicare.
"Medicare supplement policy" does not include a Medicare Advantage
plan established under Medicare Part C, an outpatient prescription
drug plan established under Medicare Part D, or a health care
prepayment plan that provides benefits pursuant to an agreement under
subparagraph (A) of paragraph (1) of subsection (a) of Section 1833
of the federal Social Security Act.
(n) "Policy form" means the form on which the policy is issued for
delivery by the issuer.
(o) "1990 standardized Medicare supplement benefit plan," "1990
standardized benefit plan," or "1990 plan" means a group or
individual policy of Medicare supplement insurance issued on or after
July 21, 1992, and with an effective date prior to June 1, 2010, and
includes Medicare supplement insurance policies and certificates
renewed on or after that date which are not replaced by the issuer at
the request of the insured.
(p) "2010 standardized Medicare supplement benefit plan," "2010
standardized benefit plan," or "2010 plan" means a group or
individual policy of Medicare supplement insurance issued with an
effective date on or after June 1, 2010.
(q) "Secretary" means the Secretary of the United States
Department of Health and Human Services.
10192.5. A policy or certificate shall not be advertised,
solicited, or issued for delivery as a Medicare supplement policy or
certificate unless the policy or certificate contains definitions or
terms that conform to the requirements of this section.
(a) (1) "Accident," "accidental injury," or "accidental means"
shall be defined to employ "result" language and shall not include
words that establish an accidental means test or use words such as
"external, violent, visible wounds" or other similar words of
description or characterization.
(2) The definition shall not be more restrictive than the
following: "injury or injuries for which benefits are provided means
accidental bodily injury sustained by the insured person that is the
direct result of an accident, independent of disease or bodily
infirmity or any other cause, and occurs while insurance coverage is
in force."
(3) The definition may provide that injuries shall not include
injuries for which benefits are provided or available under any
workers' compensation, employer's liability, or similar law, unless
prohibited by law.
(b) "Benefit period" or "Medicare benefit period" shall not be
defined more restrictively than as defined in the Medicare Program.
(c) "Convalescent nursing home," "extended care facility," or
"skilled nursing facility" shall not be defined more restrictively
than as defined in the Medicare Program.
(d) (1) "Health care expenses" means expenses of health
maintenance organizations associated with the delivery of health care
services, which expenses are analogous to incurred losses of
insurers.
(2) "Health care expenses" shall not include any of the following:
(A) Home office and overhead costs.
(B) Advertising costs.
(C) Commissions and other acquisition costs.
(D) Taxes.
(E) Capital costs.
(F) Administrative costs.
(G) Claims processing costs.
(e) "Hospital" may be defined in relation to its status,
facilities, and available services or to reflect its accreditation by
the Joint Commission on Accreditation of Hospitals, but not more
restrictively than as defined in the Medicare Program.
(f) "Medicare" shall be defined in the policy and certificate.
"Medicare" may be substantially defined as "The Health Insurance for
the Aged Act, Title XVIII of the Social Security Amendments of 1965,
as amended," or "Title I, Part I of Public Law 89-97, as enacted by
the 89th Congress and popularly known as the Health Insurance for the
Aged Act, as amended," or words of similar import.
(g) "Medicare eligible expenses" shall mean expenses of the kinds
covered by Medicare Parts A and B, to the extent recognized as
reasonable and medically necessary by Medicare.
(h) "Physician" shall not be defined more restrictively than as
defined in the Medicare Program.
(i) (1) "Sickness" shall not be defined more restrictively than as
follows: "sickness means illness or disease of an insured person
that first manifests itself after the effective date of insurance and
while the insurance is in force."
(2) The definition may be further modified to exclude sicknesses
or diseases for which benefits are provided under any workers'
compensation, occupational disease, employer's liability, or similar
law.
10192.55. (a) With regard to Medicare supplement policies, all
insurers, brokers, agents, and others engaged in the business of
insurance owe a policyholder or a prospective policyholder a duty of
honesty, and a duty of good faith and fair dealing.
(b) Conduct of an insurer, broker, or agent during the offer and
sale of a Medicare supplement policy previous to the purchase is
relevant to any action alleging a breach of the duty of honesty, and
a duty of good faith and fair dealing set forth in subdivision (a).
10192.6. (a) Except for permitted preexisting condition clauses as
described in Sections 10192.7, 10192.8, and 10192.81, a policy or
certificate shall not be advertised, solicited, or issued for
delivery as a Medicare supplement policy if the policy or certificate
contains limitations or exclusions on coverage that are more
restrictive than those of Medicare.
(b) A Medicare supplement policy or certificate shall not use
waivers to exclude, limit, or reduce coverage or benefits for
specifically named or described preexisting diseases or physical
conditions.
(c) A Medicare supplement policy or certificate in force shall not
contain benefits that duplicate benefits provided by Medicare.
(d) (1) Subject to paragraphs (4) and (5) of subdivision (a) of
Section 10192.8, a Medicare supplement policy with benefits for
outpatient prescription drugs that was issued prior to January 1,
2006, shall be renewed for current policyholders, at the option of
the policyholder, who do not enroll in Medicare Part D.
(2) A Medicare supplement policy with benefits for outpatient
prescription drugs shall not be issued on and after January 1, 2006.
(3) On and after January 1, 2006, a Medicare supplement policy
with benefits for outpatient prescription drugs shall not be renewed
after the policyholder enrolls in Medicare Part D unless both of the
following conditions exist:
(A) The policy is modified to eliminate outpatient prescription
drug coverage for outpatient prescription drug expenses incurred
after the effective date of the individual's coverage under a
Medicare Part D plan.
(B) The premium is adjusted to reflect the elimination of
outpatient prescription drug coverage at the time of enrollment in
Medicare Part D, accounting for any claims paid if applicable.
10192.7. A policy or certificate shall not be advertised,
solicited, or issued for delivery as a Medicare supplement policy or
certificate prior to January 1, 2001, unless it meets or exceeds
requirements applicable pursuant to this code that were in effect
prior to that date.
10192.8. The following standards are applicable to all Medicare
supplement policies or certificates advertised, solicited, or issued
for delivery on or after January 1, 2001, and with an effective date
prior to June 1, 2010. A policy or certificate shall not be
advertised, solicited, or issued for delivery as a Medicare
supplement policy or certificate unless it complies with these
benefit standards.
(a) The following general standards apply to Medicare supplement
policies and certificates and are in addition to all other
requirements of this article:
(1) A Medicare supplement policy or certificate shall not exclude
or limit benefits for losses incurred more than six months from the
effective date of coverage because it involved a preexisting
condition. The policy or certificate shall not define a preexisting
condition more restrictively than a condition for which medical
advice was given or treatment was recommended by or received from a
physician within six months before the effective date of coverage.
(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 modified to correspond with those changes.
(4) A Medicare supplement policy or certificate shall not provide
for termination of coverage of a spouse solely because of the
occurrence of an event specified for termination of coverage of the
insured, other than the nonpayment of premium.
(5) Each Medicare supplement policy shall be guaranteed renewable
or noncancelable.
(A) The issuer shall not cancel or nonrenew the policy solely on
the ground of health status of the individual.
(B) The issuer shall not cancel or nonrenew the policy for any
reason other than nonpayment of premium or misrepresentation which is
shown by the issuer to be material to the acceptance for coverage.
The contestability period for Medicare supplement insurance shall be
two years.
(C) If the Medicare supplement policy is terminated by the master
policyholder and is not replaced as provided under subparagraph (E),
the issuer shall offer certificate holders an individual Medicare
supplement policy that, at the option of the certificate holder,
either provides for continuation of the benefits contained in the
group policy or provides for benefits that otherwise meet the
requirements of one of the standardized policies defined in this
article.
(D) If an individual is a certificate holder in a group Medicare
supplement policy and membership in the group is terminated, the
issuer shall either offer the certificate holder the conversion
opportunity described in subparagraph (C) or, at the option of the
group policyholder, shall offer the certificate holder continuation
of coverage under the group policy.
(E) (i) If a group Medicare supplement policy is replaced by
another group Medicare supplement policy purchased by the same
policyholder, the issuer of the replacement policy shall offer
coverage to all persons covered under the old group policy on its
date of termination. Coverage under the new policy shall not result
in any exclusion for preexisting conditions that would have been
covered under the group policy being replaced.
(ii) If a Medicare supplement policy or certificate replaces
another Medicare supplement policy or certificate that has been in
force for six months or more, the replacing issuer shall not impose
an exclusion or limitation based on a preexisting condition. If the
original coverage has been in force for less than six months, the
replacing issuer shall waive any time period applicable to
preexisting conditions, waiting periods, elimination periods, or
probationary periods in the new policy or certificate to the extent
the time was spent under the original coverage.
(F) 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 (P.L. 108-173), the policy as modified as a result of that act
shall be deemed to satisfy the guaranteed renewal requirements of
this paragraph.
(6) Termination of a Medicare supplement policy or certificate
shall be without prejudice to any continuous loss that commenced
while the policy 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 insured, limited to the
duration of the policy benefit period, if any, or to payment of the
maximum benefits. Receipt of Medicare Part D benefits shall not be
considered in determining a continuous loss.
(7) (A) (i) A Medicare supplement policy or certificate shall
provide that benefits and premiums under the policy or certificate
shall be suspended at the request of the policyholder or certificate
holder for the period, not to exceed 24 months, in which the
policyholder or certificate holder has applied for and is determined
to be entitled to Medi-Cal, but only if the policyholder or
certificate holder notifies the issuer of the policy or certificate
within 90 days after the date the individual becomes entitled to
assistance. Upon receipt of timely notice, the insurer shall return
directly to the insured that portion of the premium attributable to
the period of Medi-Cal eligibility, subject to adjustment for paid
claims. If suspension occurs and if the policyholder or certificate
holder loses entitlement to Medi-Cal, the policy or certificate shall
be automatically reinstituted (effective as of the date of
termination of entitlement) as of the termination of entitlement if
the policyholder or certificate holder provides notice of loss of
entitlement within 90 days after the date of loss and pays the
premium attributable to the period, effective as of the date of
termination of entitlement, or equivalent coverage shall be provided
if the prior form is no longer available.
(ii) A Medicare supplement policy or certificate shall provide
that benefits and premiums under the policy or certificate shall be
suspended at the request of the policyholder or certificate holder
for any period that may be provided by federal regulation if the
policyholder is entitled to benefits under Section 226(b) of the
Social Security Act and is covered under a group health plan, as
defined in Section 1862(b)(1)(A)(v) of the Social Security Act. If
suspension occurs and the policyholder or certificate holder loses
coverage under the group health plan, the policy or certificate shall
be automatically reinstituted, effective as of the date of loss of
coverage if the policyholder provides notice within 90 days of the
date of the loss of coverage.
(B) Reinstitution of coverages:
(i) Shall not provide for any waiting period with respect to
treatment of preexisting conditions.
(ii) Shall provide for resumption of coverage that is
substantially equivalent to coverage in effect before the date of
suspension. If the suspended Medicare supplement policy provided
coverage for outpatient prescription drugs, reinstitution of the
policy for a Medicare Part D enrollee shall not include coverage for
outpatient prescription drugs but shall otherwise provide coverage
that is substantially equivalent to the coverage in effect before the
date of suspension.
(iii) Shall provide for classification of premiums on terms at
least as favorable to the policyholder or certificate holder as the
premium classification terms that would have applied to the
policyholder or certificate holder had the coverage not been
suspended.
(8) If an issuer makes a written offer to the Medicare supplement
policyholders or certificate holders of one or more of its plans, to
exchange during a specified period from his or her 1990 standardized
plan, as described in Section 10192.9, to a 2010 standardized plan,
as described in Section 10192.91, the offer and subsequent exchange
shall comply with the following requirements:
(A) An issuer need not provide justification to the commissioner
if the insured replaces a 1990 standardized policy or certificate
with an issue age rated 2010 standardized policy or certificate at
the insured's original issue age and duration. If an insured's policy
or certificate to be replaced is priced on an issue age rate
schedule at the time of that offer, the rate charged to the insured
for the new exchanged policy shall recognize the policy reserve
buildup, due to the prefunding inherent in the use of an issue age
rate basis, for the benefit of the insured. The method proposed to be
used by an issuer shall be filed with the commissioner.
(B) The rating class of the new policy or certificate shall be the
class closest to the insured's class of the replaced coverage.
(C) An issuer shall not apply new preexisting condition
limitations or a new incontestability period to the new policy for
those benefits contained in the exchanged 1990 standardized policy or
certificate of the insured, but may apply preexisting condition
limitations of no more than six months to any added benefits
contained in the new 2010 standardized policy or certificate not
contained in the exchanged policy. This subparagraph shall not apply
to an applicant who is guaranteed issue under Section 10192.11 or
10192.12.
(D) The new policy or certificate shall be offered to all
policyholders or certificate holders within a given plan, except
where the offer or issue would be in violation of state or federal
law.
(9) A Medicare supplement policy shall not limit coverage
exclusively to a single disease or affliction.
(b) With respect to the standards for basic (core) benefits for
benefit plans A to J, inclusive, every issuer shall make available a
policy or certificate including only the following basic "core"
package of benefits to each prospective insured. An issuer may make
available to prospective insureds any of the other Medicare
supplement insurance benefit plans in addition to the basic core
package, but not in lieu of it. However, the benefits described in
paragraphs (6) and (7) shall not be offered so long as California is
required to disallow these benefits for Medicare beneficiaries by the
Centers for Medicare and Medicaid Services or other agent of the
federal government under Section 1395ss of Title 42 of the United
States Code.
(1) Coverage of Part A Medicare eligible expenses for
hospitalization to the extent not covered by Medicare from the 61st
day to the 90th day, inclusive, in any Medicare benefit period.
(2) Coverage of Part A Medicare eligible expenses incurred for
hospitalization to the extent not covered by Medicare for each
Medicare lifetime inpatient reserve day used.
(3) 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
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.
(4) Coverage under Medicare Parts A and 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.
(5) Coverage for the coinsurance amount, or in the case of
hospital outpatient department services, the copayment amount, of
Medicare eligible expenses under Part B regardless of hospital
confinement, subject to the Medicare Part B deductible.
(6) Coverage of the actual cost, up to the legally billed amount,
of an annual mammogram as provided in Section 10123.81, to the extent
not paid by Medicare.
(7) Coverage of the actual cost, up to the legally billed amount,
of an annual cervical cancer screening test as provided in Section
10123.18, to the extent not paid by Medicare.
(c) The following additional benefits shall be included in
Medicare supplement benefit plans B to J, inclusive, only as provided
by Section 10192.9.
(1) With respect to the Medicare Part A deductible, coverage for
all of the Medicare Part A inpatient hospital deductible amount per
benefit period.
(2) With respect to skilled nursing facility care, coverage for
the actual billed charges up to the coinsurance amount from the 21st
day to the 100th day, inclusive, in a Medicare benefit period for
posthospital skilled nursing facility care eligible under Medicare
Part A.
(3) With respect to the Medicare Part B deductible, coverage for
all of the Medicare Part B deductible amount per calendar year
regardless of hospital confinement.
(4) With respect to 80 percent of the Medicare Part B excess
charges, coverage for 80 percent of the difference between the actual
Medicare Part B charge as billed, not to exceed any charge
limitation established by the Medicare Program or state law, and the
Medicare-approved Part B charge. If the insurer limits payment to a
limiting charge, the insurer has the burden to establish that amount
as the legal limit.
(5) With respect to 100 percent of the Medicare Part B excess
charges, coverage for all of the difference between the actual
Medicare Part B charge as billed, not to exceed any charge limitation
established by the Medicare Program or state law, and the
Medicare-approved Part B charge. If the insurer limits payment to a
limiting charge, the insurer has the burden to establish that amount
as the legal limit.
(6) With respect to the basic outpatient prescription drug
benefit, coverage for 50 percent of outpatient prescription drug
charges, after a two hundred fifty dollar ($250) calendar year
deductible, to a maximum of one thousand two hundred fifty dollars
($1,250) in benefits received by the insured per calendar year, to
the extent not covered by Medicare. On and after January 1, 2006, no
Medicare supplement policy may be sold or issued if it includes a
prescription drug benefit.
(7) With respect to the extended outpatient prescription drug
benefit, coverage for 50 percent of outpatient prescription drug
charges, after a two hundred fifty dollar ($250) calendar year
deductible, to a maximum of three thousand dollars ($3,000) in
benefits received by the insured per calendar year, to the extent not
covered by Medicare. On and after January 1, 2006, no Medicare
supplement policy may be sold or issued if it includes a prescription
drug benefit.
(8) With respect to medically necessary emergency care in a
foreign country, coverage to the extent not covered by Medicare for
80 percent of the billed charges for Medicare-eligible expenses for
medically necessary emergency hospital, physician, and medical care
received in a foreign country, which care would have been covered by
Medicare if provided in the United States and which care began during
the first 60 consecutive days of each trip outside the United
States, subject to a calendar year deductible of two hundred fifty
dollars ($250), and a lifetime maximum benefit of fifty thousand
dollars ($50,000). For purposes of this benefit, "emergency care"
shall mean care needed immediately because of an injury or an illness
of sudden and unexpected onset.
(9) With respect to the following, reimbursement shall be for the
actual charges up to 100 percent of the Medicare-approved amount for
each service, as if Medicare were to cover the service as identified
in American Medical Association Current Procedural Terminology (AMA
CPT) codes, up to a maximum of one hundred twenty dollars ($120)
annually under this benefit, however, this benefit shall not include
payment for any procedure covered by Medicare:
(A) An annual clinical preventive medical history and physical
examination that may include tests and services from subparagraph (B)
and patient education to address preventive health care measures.
(B) The following screening tests or preventive services that are
not covered by Medicare, the selection and frequency of which are
determined to be medically appropriate by the attending physician:
(i) Fecal occult blood test.
(ii) Mammogram.
(C) Influenza vaccine administered at any appropriate time during
the year.
(10) With respect to the at-home recovery benefit, coverage for
the actual charges up to forty dollars ($40) per visit and an annual
maximum of one thousand six hundred dollars ($1,600) per year to
provide short-term, at-home assistance with activities of daily
living for those recovering from an illness, injury, or surgery.
(A) For purposes of this benefit, the following definitions shall
apply:
(i) "Activities of daily living" include, but are not limited to,
bathing, dressing, personal hygiene, transferring, eating,
ambulating, assistance with drugs that are normally
self-administered, and changing bandages or other dressings.
(ii) "Care provider" means a duly qualified or licensed home
health aide or homemaker, or a personal care aide or nurse provided
through a licensed home health care agency or referred by a licensed
referral agency or licensed nurses registry.
(iii) "Home" shall mean any place used by the insured as a place
of residence, provided that the place would qualify as a residence
for home health care services covered by Medicare. A hospital or
skilled nursing facility shall not be considered the insured's place
of residence.
(iv) "At-home recovery visit" means the period of a visit required
to provide at-home recovery care, without any limit on the duration
of the visit, except that each consecutive four hours in a 24-hour
period of services provided by a care provider is one visit.
(B) With respect to coverage requirements and limitations, the
following shall apply:
(i) At-home recovery services provided shall be primarily services
that assist in activities of daily living.
(ii) The insured's attending physician shall certify that the
specific type and frequency of at-home recovery services are
necessary because of a condition for which a home care plan of
treatment was approved by Medicare.
(iii) Coverage is limited to the following:
(I) No more than the number and type of at-home recovery visits
certified as necessary by the insured's attending physician. The
total number of at-home recovery visits shall not exceed the number
of Medicare-approved home health care visits under a
Medicare-approved home care plan of treatment.
(II) The actual charges for each visit up to a maximum
reimbursement of forty dollars ($40) per visit.
(III) One thousand six hundred dollars ($1,600) per calendar year.
(IV) Seven visits in any one week.
(V) Care furnished on a visiting basis in the insured's home.
(VI) Services provided by a care provider as defined in
subparagraph (A).
(VII) At-home recovery visits while the insured is covered under
the policy or certificate and not otherwise excluded.
(VIII) At-home recovery visits received during the period the
insured is receiving Medicare-approved home care services or no more
than eight weeks after the service date of the last Medicare-approved
home health care visit.
(C) Coverage is excluded for the following:
(i) Home care visits paid for by Medicare or other government
programs.
(ii) Care provided by family members, unpaid volunteers, or
providers who are not care providers.
(d) The standardized Medicare supplement benefit plan "K" shall
consist of the following benefits:
(1) Coverage of 100 percent of the Medicare Part A hospital
coinsurance amount for each day used from the 61st to the 90th day,
inclusive, in any Medicare benefit period.
(2) Coverage of 100 percent of the Medicare Part A hospital
coinsurance amount for each Medicare lifetime inpatient reserve day
used from the 91st to the 150th day, inclusive, in any Medicare
benefit period.
(3) 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 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 for this benefit as payment in full and shall not bill the
insured for any balance.
(4) With respect to the 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
described in paragraph (10) is met.
(5) With respect to skilled nursing facility care, coverage for 50
percent of the coinsurance amount for each day used from the 21st
day to the 100th day, inclusive, in a Medicare benefit period for
posthospital skilled nursing facility care eligible under Medicare
Part A until the out-of-pocket limitation described in paragraph (10)
is met.
(6) With respect to hospice care, coverage for 50 percent of cost
sharing for all Medicare Part A eligible expenses and respite care
until the out-of-pocket limitation described in paragraph (10) is
met.
(7) 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 described in paragraph (10) is
met.
(8) Except for coverage provided in paragraph (9), 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 (10).
(9) Coverage of 100 percent of the cost sharing for Medicare Part
B preventive services, after the policyholder pays the Medicare Part
B deductible.
(10) 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 four thousand dollars
($4,000) in 2006, indexed each year by the appropriate inflation
adjustment specified by the secretary.
(e) The standardized Medicare supplement benefit plan "L" shall
consist of the following benefits:
(1) The benefits described in paragraphs (1), (2), (3), and (9) of
subdivision (d).
(2) With respect to the Medicare Part A deductible, coverage for
75 percent of the Medicare Part A inpatient hospital deductible
amount per benefit period until the out-of-pocket limitation
described in paragraph (8) is met.
(3) With respect to skilled nursing facility care, coverage for 75
percent of the coinsurance amount for each day used from the 21st
day to the 100th day, inclusive, in a Medicare benefit period for
posthospital skilled nursing facility care eligible under Medicare
Part A until the out-of-pocket limitation described in paragraph (8)
is met.
(4) With respect to hospice care, coverage for 75 percent of cost
sharing for all Medicare Part A eligible expenses and respite care
until the out-of-pocket limitation described in paragraph (8) is met.
(5) Coverage for 75 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 described in paragraph (8) is met.
(6) Except for coverage provided in paragraph (7), coverage for 75
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 described in paragraph (8) is met.
(7) Coverage for 100 percent of the cost sharing for Medicare Part
B preventive services after the policyholder pays the Part B
deductible.
(8) Coverage of 100 percent of the cost sharing for 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 two thousand dollars ($2,000) in 2006,
indexed each year by the appropriate inflation adjustment specified
by the secretary.
(f) An issuer shall prominently indicate through text edits, or by
other means acceptable to the commissioner, an amendment made to a
Medicare supplement policy form that the department previously
approved on the basis that the amendment is consistent with this
section. The department may, in its discretion, restrict its review
to amendments made to Medicare supplement policy forms that have not
previously been found consistent with this section in order to
facilitate the availability of amended policy forms that are
consistent with the federal Medicare Modernization Act. The
department shall not restrict its review if the amendment makes
additional changes to the Medicare supplement policy form.
10192.81. The following standards are applicable to all Medicare
supplement policies or certificates delivered or issued for delivery
in this state with an effective date 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 on or after June 1, 2010.
Benefit standards applicable to Medicare supplement policies and
certificates issued with an effective date prior to June 1, 2010,
remain subject to the requirements of Section 10192.8.
(a) The following general standards apply to Medicare supplement
policies and certificates and are in addition to all other
requirements of this article:
(1) A Medicare supplement policy or certificate shall not exclude
or limit benefits for losses incurred more than six months from the
effective date of coverage because it involved a preexisting
condition. The policy or certificate shall not define a preexisting
condition more restrictively than a condition for which medical
advice was given or treatment was recommended by or received from a
physician within six months before the effective date of coverage.
(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 modified to correspond with those changes.
(4) A Medicare supplement policy or certificate shall not provide
for termination of coverage of a spouse solely because of the
occurrence of an event specified for termination of coverage of the
insured, other than the nonpayment of premium.
(5) Each Medicare supplement policy shall be guaranteed renewable.
(A) The issuer shall not cancel or nonrenew the policy solely on
the ground of health status of the individual.
(B) The issuer shall not cancel or nonrenew the policy for any
reason other than nonpayment of premium or material misrepresentation
which is shown by the issuer to be material to the acceptance for
coverage. The contestability period for Medicare supplement insurance
shall be two years, pursuant to Section 10350.2.
(C) If the Medicare supplement policy is terminated by the master
policyholder and is not replaced as provided under subparagraph (E),
the issuer shall offer certificate holders an individual Medicare
supplement policy which, at the option of the certificate holder,
does one of the following:
(i) Provides for continuation of the benefits contained in the
group policy.
(ii) Provides for benefits that otherwise meet the requirements of
one of the standardized policies defined in this article.
(D) If an individual is a certificate holder in a group Medicare
supplement policy and the individual terminates membership in the
group, the issuer shall do one of the following:
(i) Offer the certificate holder the conversion opportunity
described in subparagraph (C).
(ii) At the option of the group policyholder, offer the
certificate holder continuation of coverage under the group policy.
(E) (i) If a group Medicare supplement policy is replaced by
another group Medicare supplement policy purchased by the same
policyholder, the issuer of the replacement policy shall offer
coverage to all persons covered under the old group policy on its
date of termination. Coverage under the new policy shall not result
in any exclusion for preexisting conditions that would have been
covered under the group policy being replaced.
(ii) If a Medicare supplement policy or certificate replaces
another Medicare supplement policy or certificate that has been in
force for six months or more, the replacing issuer shall not impose
an exclusion or limitation based on a preexisting condition. If the
original coverage has been in force for less than six months, the
replacing issuer shall waive any time period applicable to
preexisting conditions, waiting periods, elimination periods, or
probationary periods in the new policy or certificate to the extent
the time was spent under the original coverage.
(6) Termination of a Medicare supplement policy or certificate
shall be without prejudice to any continuous loss that commenced
while the policy 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 insured, limited to the
duration of the policy benefit period, if any, or payment of the
maximum benefits. Receipt of Medicare Part D benefits shall not be
considered in determining a continuous loss.
(7) (A) (i) A Medicare supplement policy or certificate shall
provide that benefits and premiums under the policy or certificate
shall be suspended at the request of the policyholder or certificate
holder for the period, not to exceed 24 months, in which the
policyholder or certificate holder has applied for and is determined
to be entitled to medical assistance under Medi-Cal, but only if the
policyholder or certificate holder notifies the issuer of the policy
or certificate within 90 days after the date the individual becomes
entitled to assistance. Upon receipt of timely notice, the insurer
shall return directly to the insured that portion of the premium
attributable to the period of Medi-Cal eligibility, subject to
adjustment for paid claims.
(ii) If suspension occurs and if the policyholder or certificate
holder loses entitlement to medical assistance under Medi-Cal, the
policy or certificate shall be automatically reinstituted (effective
as of the date of termination of entitlement) as of the termination
of entitlement if the policyholder or certificate holder provides
notice of loss of entitlement within 90 days after the date of loss
and pays the premium attributable to the period, effective as of the
date of termination of entitlement or equivalent coverage shall be
provided if the prior form is no longer available.
(iii) Each Medicare supplement policy shall provide that benefits
and premiums under the policy shall be suspended (for any period that
may be provided by federal regulation) at the request of the
policyholder if the policyholder is entitled to benefits under
Section 226(b) of the federal Social Security Act and is covered
under a group health plan (as defined in Section 1862(b)(1)(A)(v) of
the federal Social Security Act). If suspension occurs and if the
policyholder or certificate holder loses coverage under the group
health plan, the policy shall be automatically reinstituted
(effective as of the date of loss of coverage) if the policyholder
provides notice of loss of coverage within 90 days after the date of
the loss and pays the applicable premium.
(B) Reinstitution of coverages shall comply with all of the
following requirements:
(i) Not provide for any waiting period with respect to treatment
of preexisting conditions.
(ii) Provide for resumption of coverage that is substantially
equivalent to coverage in effect before the date of suspension.
(iii) Provide for classification of premiums on terms at least as
favorable to the policyholder or certificate holder as the premium
classification terms that would have applied to the policyholder or
certificate holder had the coverage not been suspended.
(8) A Medicare supplement policy shall not limit coverage
exclusively to a single disease or affliction.
(9) A Medicare supplement policy shall provide an examination
period of 30 days after the receipt of the policy by the applicant
for purposes of review, during which time the applicant may return
the policy as described in subdivision (e) of Section 10192.17.
(b) With respect to the standards for basic (core) benefits for
benefit plans A, B, C, D, F, high deductible F, G, M, and N, every
issuer of Medicare supplement insurance benefit plans shall make
available a policy or certificate including only the following basic
"core" package of benefits to each prospective insured. An issuer may
make available to prospective insureds any of the other Medicare
Supplement Insurance Benefit Plans in addition to the basic (core)
package, but not in lieu of it. However, the benefits described in
paragraphs (7) and (8) shall not be offered so long as California is
required to disallow these benefits for Medicare beneficiaries by the
Centers for Medicare and Medicaid Services or other agent of the
federal government under Section 1395ss of Title 42 of the United
States Code.
(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, inclusive, in any Medicare benefit period.
(2) Coverage of Part A Medicare eligible expenses incurred for
hospitalization to the extent not covered by Medicare for each
Medicare lifetime inpatient reserve day used.
(3) 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.
(4) Coverage under Medicare Parts A and 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.
(5) Coverage for the coinsurance amount, or in the case of
hospital outpatient department services paid under a prospective
payment system, the copayment amount, of Medicare eligible expenses
under Part B regardless of hospital confinement, subject to the
Medicare Part B deductible.
(6) Coverage of cost sharing for all Part A Medicare eligible
hospice care and respite care expenses.
(7) Coverage of the actual cost, up to the legally billed amount,
of an annual mammogram as provided in Section 10123.81, to the extent
not paid by Medicare.
(8) Coverage of the actual cost, up to the legally billed amount,
of an annual cervical cancer screening test as provided in Section
10123.18, to the extent not paid by Medicare.
(c) The following additional benefits shall be included in
Medicare supplement benefit plans B, C, D, F, high deductible F, G,
M, and N, consistent with the plan type and benefits for each plan as
provided in Section 10192.91:
(1) With respect to the Medicare Part A deductible, coverage for
100 percent of the Medicare Part A inpatient hospital deductible
amount per benefit period.
(2) With respect to the Medicare Part A deductible, coverage for
50 percent of the Medicare Part A inpatient hospital deductible
amount per benefit period.
(3) With respect to skilled nursing facility care, coverage for
the actual billed charges up to the coinsurance amount from the 21st
day through the 100th day in a Medicare benefit period for
posthospital skilled nursing facility care eligible under Medicare
Part A.
(4) With respect to the Medicare Part B deductible, coverage for
100 percent of the Medicare Part B deductible amount per calendar
year regardless of hospital confinement.
(5) With respect to 100 percent of the Medicare Part B excess
charges, coverage for all of the difference between the actual
Medicare Part B charges as billed, not to exceed any charge
limitation established by the Medicare Program or state law, and the
Medicare-approved Part B charge.
(6) With respect to medically necessary emergency care in a
foreign country, coverage to the extent not covered by Medicare for
80 percent of the billed charges for Medicare-eligible expenses for
medically necessary emergency hospital, physician, and medical care
received in a foreign country, which care would have been covered by
Medicare if provided in the United States and which care began during
the first 60 consecutive days of each trip outside the United
States, subject to a calendar year deductible of two hundred fifty
dollars ($250), and a lifetime maximum benefit of fifty thousand
dollars ($50,000). For purposes of this benefit, "emergency care"
shall mean care needed immediately because of an injury or an illness
of sudden and unexpected onset.
10192.9. The following standards are applicable to all Medicare
supplement policies or certificates delivered or issued for delivery
in this state on or after July 1, 1992, and with an effective date
prior to June 1, 2010.
(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 subdivision
(b) of Section 10192.8.
(b) 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 by subdivision (f)
and by Section 10192.10.
(c) Benefit plans shall be uniform in structure, language,
designation and format to the standard benefit plans A to L,
inclusive, listed in subdivision (e), and shall conform to the
definitions in Section 10192.4. Each benefit shall be structured in
accordance with the format provided in subdivisions (b), (c), (d),
and (e) of Section 10192.8 and list the benefits in the order listed
in subdivision (e). For purposes of this section, "structure,
language, and format" means style, arrangement, and overall content
of a benefit.
(d) An issuer may use, in addition to the benefit plan
designations required in subdivision (c), other designations to the
extent permitted by law.
(e) With respect to the makeup of benefit plans, the following
shall apply:
(1) Standardized Medicare supplement benefit plan A shall be
limited to the basic (core) benefit common to all benefit plans, as
defined in subdivision (b) of Section 10192.8.
(2) Standardized Medicare supplement benefit plan B shall include
only the following: the core benefit, plus the Medicare Part A
deductible as defined in paragraph (1) of subdivision (c) of Section
10192.8.
(3) Standardized Medicare supplement benefit plan C shall include
only the following: the core benefit, 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 paragraphs (1), (2), (3), and (8) of
subdivision (c) of Section 10192.8, respectively.
(4) Standardized Medicare supplement benefit plan D shall include
only the following: the core benefit, 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 paragraphs (1), (2), (8), and (10) of subdivision (c)
of Section 10192.8, respectively.
(5) Standardized Medicare supplement benefit plan E shall include
only the following: the core benefit, 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 paragraphs (1), (2), (8), and (9) of subdivision (c) of
Section 10192.8, respectively.
(6) Standardized Medicare supplement benefit plan F shall include
only the following: the core benefit, plus the Medicare Part A
deductible, the skilled nursing facility care, the Medicare Part B
deductible, 100 percent of the Medicare Part B excess charges, and
medically necessary emergency care in a foreign country as defined in
paragraphs (1), (2), (3), (5), and (8) of subdivision (c) of Section
10192.8, respectively.
(7) Standardized Medicare supplement benefit high deductible plan
F shall include only the following: 100 percent of covered expenses
following the payment of the annual high deductible plan F
deductible. The covered expenses include the core benefit, plus the
Medicare Part A deductible, skilled nursing facility care, the
Medicare Part B deductible, 100 percent of the Medicare Part B excess
charges, and medically necessary emergency care in a foreign country
as defined in paragraphs (1), (2), (3), (5), and (8) of subdivision
(c) of Section 10192.8, respectively. 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, as adjusted annually thereafter
by the secretary to reflect the change in the Consumer Price Index
for all urban consumers for the 12-month period ending with August of
the preceding year, and rounded to the nearest multiple of ten
dollars ($10).
(8) Standardized Medicare supplement benefit plan G shall include
only the following: the core benefit, plus the Medicare Part A
deductible, skilled nursing facility care, 80 percent of the Medicare
Part B excess charges, medically necessary emergency care in a
foreign country, and the at-home recovery benefit as defined in
paragraphs (1), (2), (4), (8), and (10) of subdivision (c) of Section
10192.8, respectively.
(9) Standardized Medicare supplement benefit plan H shall consist
of only the following: the core benefit, plus the Medicare Part A
deductible, skilled nursing facility care, basic outpatient
prescription drug benefit, and medically necessary emergency care in
a foreign country as defined in paragraphs (1), (2), (6), and (8) of
subdivision (c) of Section 10192.8, respectively. The outpatient
prescription drug benefit shall not be included in a Medicare
supplement policy sold on or after January 1, 2006.
(10) Standardized Medicare supplement benefit plan I shall consist
of only the following: the core benefit, plus the Medicare Part A
deductible, skilled nursing facility care, 100 percent of the
Medicare Part B excess charges, basic outpatient prescription drug
benefit, medically necessary emergency care in a foreign country, and
at-home recovery benefit as defined in paragraphs (1), (2), (5),
(6), (8), and (10) of subdivision (c) of Section 10192.8,
respectively. The outpatient prescription drug benefit shall not be
included in a Medicare supplement policy sold on or after January 1,
2006.
(11) Standardized Medicare supplement benefit plan J shall consist
of only the following: the core benefit, plus the Medicare Part A
deductible, skilled nursing facility care, Medicare Part B
deductible, 100 percent of the Medicare Part B excess charges,
extended outpatient prescription drug benefit, medically necessary
emergency care in a foreign country, preventive medical care, and
at-home recovery benefit as defined in paragraphs (1), (2), (3), (5),
(7), (8), (9), and (10) of subdivision (c) of Section 10192.8,
respectively. The outpatient prescription drug benefit shall not be
included in a Medicare supplement policy sold on or after January 1,
2006.
(12) Standardized Medicare supplement benefit high deductible plan
J shall consist of only the following: 100 percent of covered
expenses following the payment of the annual high deductible plan J
deductible. The covered expenses include the core benefit, plus the
Medicare Part A deductible, skilled nursing facility care, Medicare
Part B deductible, 100 percent of the Medicare Part B excess charges,
extended outpatient prescription drug benefit, medically necessary
emergency care in a foreign country, preventive medical care benefit,
and at-home recovery benefit as defined in paragraphs (1), (2), (3),
(5), (7), (8), (9), and (10) of subdivision (c) of Section 10192.8,
respectively. 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, as adjusted
annually thereafter by the secretary to reflect the change in the
Consumer Price Index for all urban consumers for the 12-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 on
or after January 1, 2006.
(13) Standardized Medicare supplement benefit plan K shall consist
of only those benefits described in subdivision (d) of Section
10192.8.
(14) Standardized Medicare supplement benefit plan L shall consist
of only those benefits described in subdivision (e) of Section
10192.8.
(f) 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, that are not otherwise available and
that are cost-effective and offered in a manner that is consistent
with the goal of simplification of Medicare supplement policies. On
and after January 1, 2006, the innovative benefit shall not include
an outpatient prescription drug benefit.
10192.91. The following standards are applicable to all Medicare
supplement policies or certificates delivered or issued for delivery
in this state with an effective date 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 plan standards.
Benefit plan standards applicable to Medicare supplement policies and
certificates issued with an effective date before June 1, 2010,
remain subject to the requirements of Section 10192.9.
(a) (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 subdivision
(b) of Section 10192.81.
(2) If an issuer makes available any of the additional benefits
described in subdivision (c) of Section 10192.81, or offers
standardized benefit plans K or L, as described in paragraphs (8) and
(9) of subdivision (e), 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 paragraph (1), a policy form or certificate form
containing either standardized benefit plan C, as described in
paragraph (3) of subdivision (e), or standardized benefit plan F, as
described in paragraph (5) of subdivision (e).
(b) 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 subdivision (f)
and by Section 10192.10.
(c) Benefit plans shall be uniform in structure, language,
designation, and format to the standard benefit plans listed in
subdivision (e) and conform to the definitions in Section 10192.4.
Each benefit shall be structured in accordance with the format
provided in subdivisions (b) and (c) of Section 10192.81; or, in the
case of plan K or L, in paragraph (8) or (9) of subdivision (e) and
list the benefits in the order shown in subdivision (e). For purpose
10192.1. All Medicare supplement policies and certificates shall
comply with the provisions of subdivision (b) of Section 10291.5 and
Chapter 7 (commencing with Section 10600) of Part 2 of Division 2,
regardless of the situs of the contract.
10192.2. The purpose of this article is to provide for the
reasonable standardization of coverage and simplification of terms
and benefits of Medicare supplement policies, to facilitate public
understanding and comparison of those policies, to eliminate
provisions contained in those policies that may be misleading or
confusing in connection with the purchase of the policies or with the
settlement of claims, and to provide for full disclosures in the
sale of Medicare supplement insurance policies to persons eligible
for Medicare.
10192.3. (a) Except as otherwise provided in this section or in
Sections 10192.7, 10192.12, 10192.13, 10192.16, and 10192.21, this
article shall apply to all Medicare supplement policies advertised,
solicited, or issued for delivery in this state on or after January
1, 2001, and to all certificates delivered in this state under a
group Medicare supplement master policy agreement that have been
advertised, solicited, or issued for delivery in this state on or
after that date.
(b) This article shall not apply to a policy or contract of one or
more employers or labor organizations, or of the trustees of a fund
established by one or more employers or labor organizations, or
combination thereof, for employees or former employees, or a
combination thereof, or for members or former members, or a
combination thereof, of the labor organizations.
(c) This article shall not apply to Medicare supplement policies
subject to Article 3.5 (commencing with Section 1358.1) of Chapter
2.2 of Division 2 of the Health and Safety Code.
(d) The commissioner may, from time to time, promulgate
regulations to implement this article.
10192.4. The following definitions apply for the purposes of this
article:
(a) "Applicant" means:
(1) The person who seeks to contract for insurance benefits, in
the case of an individual Medicare supplement policy.
(2) The proposed certificate holder, in the case of a group
Medicare supplement policy.
(b) "Bankruptcy" means that situation in which a Medicare
Advantage organization that is not an issuer has filed, or has had
filed against it, a petition for declaration of bankruptcy and has
ceased doing business in the state.
(c) "Certificate" means a certificate issued for delivery in this
state under a group Medicare supplement policy.
(d) "Certificate form" means the form on which the certificate is
issued for delivery by the issuer.
(e) "Continuous period of creditable coverage" means the period
during which an individual was covered by creditable coverage, if
during the period of the coverage the individual had no breaks in
coverage greater than 63 days.
(f) (1) "Creditable coverage" means, with respect to an
individual, coverage of the individual provided under any of the
following:
(A) Any individual or group contract, policy, certificate, or
program that is written or administered by a health care service
plan, health insurer, fraternal benefits society, self-insured
employer plan, or any other entity, in this state or elsewhere, and
that arranges or provides medical, hospital, and surgical coverage
not designed to supplement other private or governmental plans. The
term includes continuation or conversion coverage.
(B) Part A or B of Title XVIII of the federal Social Security Act
(42 U.S.C. Sec. 1395c et seq.) (Medicare).
(C) Title XIX of the federal Social Security Act (42 U.S.C. Sec.
1396 et seq.) (Medicaid (known as Medi-Cal in California)), other
than coverage consisting solely of benefits under Section 1928 of
that act.
(D) Chapter 55 of Title 10 of the United States Code (CHAMPUS).
(E) A medical care program of the Indian Health Service or of a
tribal organization.
(F) A state health benefits risk pool.
(G) A health plan offered under Chapter 89 of Title 5 of the
United States Code (Federal Employees Health Benefits Program).
(H) A public health plan as defined in federal regulations
authorized by Section 2701(c)(1)(I) of the federal Public Health
Service Act, as amended by Public Law 104-191, the federal Health
Insurance Portability and Accountability Act of 1996.
(I) A health benefit plan under Section 5(e) of the federal Peace
Corps Act (Section 2504(e) of Title 22 of the United States Code).
(J) Any other publicly sponsored program, provided in this state
or elsewhere, of medical, hospital, and surgical care.
(K) Any other creditable coverage as defined by subsection (c) of
Section 2701 of Title XXVII of the federal Public Health Service Act
(42 U.S.C. Sec. 300gg(c)).
(2) "Creditable coverage" shall not include one or more, or any
combination of, the following:
(A) Coverage only for accident or disability income insurance, or
any combination thereof.
(B) Coverage issued as a supplement to liability insurance.
(C) Liability insurance, including general liability insurance and
automobile liability insurance.
(D) Workers' compensation or similar insurance.
(E) Automobile medical payment insurance.
(F) Credit-only insurance.
(G) Coverage for onsite medical clinics.
(H) Other similar insurance coverage, specified in federal
regulations, under which benefits for medical care are secondary or
incidental to other insurance benefits.
(3) "Creditable coverage" shall not include the following benefits
if they are provided under a separate policy, certificate, or
contract of insurance or are otherwise not an integral part of the
plan:
(A) Limited scope dental or vision benefits.
(B) Benefits for long-term care, nursing home care, home health
care, community-based care, or any combination thereof.
(C) Other similar, limited benefits as are specified in federal
regulations.
(4) "Creditable coverage" shall not include the following benefits
if offered as independent, noncoordinated benefits:
(A) Coverage only for a specified disease or illness.
(B) Hospital indemnity or other fixed indemnity insurance.
(5) "Creditable coverage" shall not include the following if
offered as a separate policy, certificate, or contract of insurance:
(A) Medicare supplemental health insurance as defined under
Section 1882(g)(1) of the federal Social Security Act.
(B) Coverage supplemental to the coverage provided under Chapter
55 of Title 10 of the United States Code.
(C) Similar supplemental coverage provided to coverage under a
group health plan.
(g) "Employee welfare benefit plan" means a plan, fund, or program
of employee benefits as defined in Section 1002 of Title 29 of the
United States Code (Employee Retirement Income Security Act).
(h) "Insolvency" means when an issuer, licensed to transact the
business of insurance in this state, has had a final order of
liquidation entered against it with a finding of insolvency by a
court of competent jurisdiction in the issuer's state of domicile.
(i) "Issuer" includes insurance companies, fraternal benefit
societies, and any other entity delivering, or issuing for delivery,
Medicare supplement policies or certificates in this state, except
entities subject to Article 3.5 (commencing with Section 1358.1) of
Chapter 2.2 of Division 2 of the Health and Safety Code.
(j) "Medi-Cal" means California's version of Medicaid under Title
XIX of the federal Social Security Act.
(k) "Medicare" means the Health Insurance for the Aged Act, Title
XVIII of the Social Security Amendments of 1965, as amended.
(l) "Medicare Advantage plan" means a plan of coverage for health
benefits under Medicare Part C and includes:
(1) Coordinated care plans that provide health care services,
including, but not limited to, health care service plans (with or
without a point-of-service option), plans offered by
provider-sponsored organizations, and preferred provider
organizations plans.
(2) Medical savings account plans coupled with a contribution into
a Medicare Advantage medical savings account.
(3) Medicare Advantage private fee-for-service plans.
(m) "Medicare supplement policy" means a group or individual
policy of health insurance, other than a policy issued pursuant to a
contract under Section 1876 of the federal Social Security Act (42
U.S.C. Sec. 1395mm) or an issued policy under a demonstration project
specified in Section 1395ss(g)(1) of Title 42 of the United States
Code, that is advertised, marketed, or designed primarily as a
supplement to reimbursements under Medicare for the hospital,
medical, or surgical expenses of persons eligible for Medicare.
"Medicare supplement policy" does not include a Medicare Advantage
plan established under Medicare Part C, an outpatient prescription
drug plan established under Medicare Part D, or a health care
prepayment plan that provides benefits pursuant to an agreement under
subparagraph (A) of paragraph (1) of subsection (a) of Section 1833
of the federal Social Security Act.
(n) "Policy form" means the form on which the policy is issued for
delivery by the issuer.
(o) "1990 standardized Medicare supplement benefit plan," "1990
standardized benefit plan," or "1990 plan" means a group or
individual policy of Medicare supplement insurance issued on or after
July 21, 1992, and with an effective date prior to June 1, 2010, and
includes Medicare supplement insurance policies and certificates
renewed on or after that date which are not replaced by the issuer at
the request of the insured.
(p) "2010 standardized Medicare supplement benefit plan," "2010
standardized benefit plan," or "2010 plan" means a group or
individual policy of Medicare supplement insurance issued with an
effective date on or after June 1, 2010.
(q) "Secretary" means the Secretary of the United States
Department of Health and Human Services.
10192.5. A policy or certificate shall not be advertised,
solicited, or issued for delivery as a Medicare supplement policy or
certificate unless the policy or certificate contains definitions or
terms that conform to the requirements of this section.
(a) (1) "Accident," "accidental injury," or "accidental means"
shall be defined to employ "result" language and shall not include
words that establish an accidental means test or use words such as
"external, violent, visible wounds" or other similar words of
description or characterization.
(2) The definition shall not be more restrictive than the
following: "injury or injuries for which benefits are provided means
accidental bodily injury sustained by the insured person that is the
direct result of an accident, independent of disease or bodily
infirmity or any other cause, and occurs while insurance coverage is
in force."
(3) The definition may provide that injuries shall not include
injuries for which benefits are provided or available under any
workers' compensation, employer's liability, or similar law, unless
prohibited by law.
(b) "Benefit period" or "Medicare benefit period" shall not be
defined more restrictively than as defined in the Medicare Program.
(c) "Convalescent nursing home," "extended care facility," or
"skilled nursing facility" shall not be defined more restrictively
than as defined in the Medicare Program.
(d) (1) "Health care expenses" means expenses of health
maintenance organizations associated with the delivery of health care
services, which expenses are analogous to incurred losses of
insurers.
(2) "Health care expenses" shall not include any of the following:
(A) Home office and overhead costs.
(B) Advertising costs.
(C) Commissions and other acquisition costs.
(D) Taxes.
(E) Capital costs.
(F) Administrative costs.
(G) Claims processing costs.
(e) "Hospital" may be defined in relation to its status,
facilities, and available services or to reflect its accreditation by
the Joint Commission on Accreditation of Hospitals, but not more
restrictively than as defined in the Medicare Program.
(f) "Medicare" shall be defined in the policy and certificate.
"Medicare" may be substantially defined as "The Health Insurance for
the Aged Act, Title XVIII of the Social Security Amendments of 1965,
as amended," or "Title I, Part I of Public Law 89-97, as enacted by
the 89th Congress and popularly known as the Health Insurance for the
Aged Act, as amended," or words of similar import.
(g) "Medicare eligible expenses" shall mean expenses of the kinds
covered by Medicare Parts A and B, to the extent recognized as
reasonable and medically necessary by Medicare.
(h) "Physician" shall not be defined more restrictively than as
defined in the Medicare Program.
(i) (1) "Sickness" shall not be defined more restrictively than as
follows: "sickness means illness or disease of an insured person
that first manifests itself after the effective date of insurance and
while the insurance is in force."
(2) The definition may be further modified to exclude sicknesses
or diseases for which benefits are provided under any workers'
compensation, occupational disease, employer's liability, or similar
law.
10192.55. (a) With regard to Medicare supplement policies, all
insurers, brokers, agents, and others engaged in the business of
insurance owe a policyholder or a prospective policyholder a duty of
honesty, and a duty of good faith and fair dealing.
(b) Conduct of an insurer, broker, or agent during the offer and
sale of a Medicare supplement policy previous to the purchase is
relevant to any action alleging a breach of the duty of honesty, and
a duty of good faith and fair dealing set forth in subdivision (a).
10192.6. (a) Except for permitted preexisting condition clauses as
described in Sections 10192.7, 10192.8, and 10192.81, a policy or
certificate shall not be advertised, solicited, or issued for
delivery as a Medicare supplement policy if the policy or certificate
contains limitations or exclusions on coverage that are more
restrictive than those of Medicare.
(b) A Medicare supplement policy or certificate shall not use
waivers to exclude, limit, or reduce coverage or benefits for
specifically named or described preexisting diseases or physical
conditions.
(c) A Medicare supplement policy or certificate in force shall not
contain benefits that duplicate benefits provided by Medicare.
(d) (1) Subject to paragraphs (4) and (5) of subdivision (a) of
Section 10192.8, a Medicare supplement policy with benefits for
outpatient prescription drugs that was issued prior to January 1,
2006, shall be renewed for current policyholders, at the option of
the policyholder, who do not enroll in Medicare Part D.
(2) A Medicare supplement policy with benefits for outpatient
prescription drugs shall not be issued on and after January 1, 2006.
(3) On and after January 1, 2006, a Medicare supplement policy
with benefits for outpatient prescription drugs shall not be renewed
after the policyholder enrolls in Medicare Part D unless both of the
following conditions exist:
(A) The policy is modified to eliminate outpatient prescription
drug coverage for outpatient prescription drug expenses incurred
after the effective date of the individual's coverage under a
Medicare Part D plan.
(B) The premium is adjusted to reflect the elimination of
outpatient prescription drug coverage at the time of enrollment in
Medicare Part D, accounting for any claims paid if applicable.
10192.7. A policy or certificate shall not be advertised,
solicited, or issued for delivery as a Medicare supplement policy or
certificate prior to January 1, 2001, unless it meets or exceeds
requirements applicable pursuant to this code that were in effect
prior to that date.
10192.8. The following standards are applicable to all Medicare
supplement policies or certificates advertised, solicited, or issued
for delivery on or after January 1, 2001, and with an effective date
prior to June 1, 2010. A policy or certificate shall not be
advertised, solicited, or issued for delivery as a Medicare
supplement policy or certificate unless it complies with these
benefit standards.
(a) The following general standards apply to Medicare supplement
policies and certificates and are in addition to all other
requirements of this article:
(1) A Medicare supplement policy or certificate shall not exclude
or limit benefits for losses incurred more than six months from the
effective date of coverage because it involved a preexisting
condition. The policy or certificate shall not define a preexisting
condition more restrictively than a condition for which medical
advice was given or treatment was recommended by or received from a
physician within six months before the effective date of coverage.
(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 modified to correspond with those changes.
(4) A Medicare supplement policy or certificate shall not provide
for termination of coverage of a spouse solely because of the
occurrence of an event specified for termination of coverage of the
insured, other than the nonpayment of premium.
(5) Each Medicare supplement policy shall be guaranteed renewable
or noncancelable.
(A) The issuer shall not cancel or nonrenew the policy solely on
the ground of health status of the individual.
(B) The issuer shall not cancel or nonrenew the policy for any
reason other than nonpayment of premium or misrepresentation which is
shown by the issuer to be material to the acceptance for coverage.
The contestability period for Medicare supplement insurance shall be
two years.
(C) If the Medicare supplement policy is terminated by the master
policyholder and is not replaced as provided under subparagraph (E),
the issuer shall offer certificate holders an individual Medicare
supplement policy that, at the option of the certificate holder,
either provides for continuation of the benefits contained in the
group policy or provides for benefits that otherwise meet the
requirements of one of the standardized policies defined in this
article.
(D) If an individual is a certificate holder in a group Medicare
supplement policy and membership in the group is terminated, the
issuer shall either offer the certificate holder the conversion
opportunity described in subparagraph (C) or, at the option of the
group policyholder, shall offer the certificate holder continuation
of coverage under the group policy.
(E) (i) If a group Medicare supplement policy is replaced by
another group Medicare supplement policy purchased by the same
policyholder, the issuer of the replacement policy shall offer
coverage to all persons covered under the old group policy on its
date of termination. Coverage under the new policy shall not result
in any exclusion for preexisting conditions that would have been
covered under the group policy being replaced.
(ii) If a Medicare supplement policy or certificate replaces
another Medicare supplement policy or certificate that has been in
force for six months or more, the replacing issuer shall not impose
an exclusion or limitation based on a preexisting condition. If the
original coverage has been in force for less than six months, the
replacing issuer shall waive any time period applicable to
preexisting conditions, waiting periods, elimination periods, or
probationary periods in the new policy or certificate to the extent
the time was spent under the original coverage.
(F) 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 (P.L. 108-173), the policy as modified as a result of that act
shall be deemed to satisfy the guaranteed renewal requirements of
this paragraph.
(6) Termination of a Medicare supplement policy or certificate
shall be without prejudice to any continuous loss that commenced
while the policy 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 insured, limited to the
duration of the policy benefit period, if any, or to payment of the
maximum benefits. Receipt of Medicare Part D benefits shall not be
considered in determining a continuous loss.
(7) (A) (i) A Medicare supplement policy or certificate shall
provide that benefits and premiums under the policy or certificate
shall be suspended at the request of the policyholder or certificate
holder for the period, not to exceed 24 months, in which the
policyholder or certificate holder has applied for and is determined
to be entitled to Medi-Cal, but only if the policyholder or
certificate holder notifies the issuer of the policy or certificate
within 90 days after the date the individual becomes entitled to
assistance. Upon receipt of timely notice, the insurer shall return
directly to the insured that portion of the premium attributable to
the period of Medi-Cal eligibility, subject to adjustment for paid
claims. If suspension occurs and if the policyholder or certificate
holder loses entitlement to Medi-Cal, the policy or certificate shall
be automatically reinstituted (effective as of the date of
termination of entitlement) as of the termination of entitlement if
the policyholder or certificate holder provides notice of loss of
entitlement within 90 days after the date of loss and pays the
premium attributable to the period, effective as of the date of
termination of entitlement, or equivalent coverage shall be provided
if the prior form is no longer available.
(ii) A Medicare supplement policy or certificate shall provide
that benefits and premiums under the policy or certificate shall be
suspended at the request of the policyholder or certificate holder
for any period that may be provided by federal regulation if the
policyholder is entitled to benefits under Section 226(b) of the
Social Security Act and is covered under a group health plan, as
defined in Section 1862(b)(1)(A)(v) of the Social Security Act. If
suspension occurs and the policyholder or certificate holder loses
coverage under the group health plan, the policy or certificate shall
be automatically reinstituted, effective as of the date of loss of
coverage if the policyholder provides notice within 90 days of the
date of the loss of coverage.
(B) Reinstitution of coverages:
(i) Shall not provide for any waiting period with respect to
treatment of preexisting conditions.
(ii) Shall provide for resumption of coverage that is
substantially equivalent to coverage in effect before the date of
suspension. If the suspended Medicare supplement policy provided
coverage for outpatient prescription drugs, reinstitution of the
policy for a Medicare Part D enrollee shall not include coverage for
outpatient prescription drugs but shall otherwise provide coverage
that is substantially equivalent to the coverage in effect before the
date of suspension.
(iii) Shall provide for classification of premiums on terms at
least as favorable to the policyholder or certificate holder as the
premium classification terms that would have applied to the
policyholder or certificate holder had the coverage not been
suspended.
(8) If an issuer makes a written offer to the Medicare supplement
policyholders or certificate holders of one or more of its plans, to
exchange during a specified period from his or her 1990 standardized
plan, as described in Section 10192.9, to a 2010 standardized plan,
as described in Section 10192.91, the offer and subsequent exchange
shall comply with the following requirements:
(A) An issuer need not provide justification to the commissioner
if the insured replaces a 1990 standardized policy or certificate
with an issue age rated 2010 standardized policy or certificate at
the insured's original issue age and duration. If an insured's policy
or certificate to be replaced is priced on an issue age rate
schedule at the time of that offer, the rate charged to the insured
for the new exchanged policy shall recognize the policy reserve
buildup, due to the prefunding inherent in the use of an issue age
rate basis, for the benefit of the insured. The method proposed to be
used by an issuer shall be filed with the commissioner.
(B) The rating class of the new policy or certificate shall be the
class closest to the insured's class of the replaced coverage.
(C) An issuer shall not apply new preexisting condition
limitations or a new incontestability period to the new policy for
those benefits contained in the exchanged 1990 standardized policy or
certificate of the insured, but may apply preexisting condition
limitations of no more than six months to any added benefits
contained in the new 2010 standardized policy or certificate not
contained in the exchanged policy. This subparagraph shall not apply
to an applicant who is guaranteed issue under Section 10192.11 or
10192.12.
(D) The new policy or certificate shall be offered to all
policyholders or certificate holders within a given plan, except
where the offer or issue would be in violation of state or federal
law.
(9) A Medicare supplement policy shall not limit coverage
exclusively to a single disease or affliction.
(b) With respect to the standards for basic (core) benefits for
benefit plans A to J, inclusive, every issuer shall make available a
policy or certificate including only the following basic "core"
package of benefits to each prospective insured. An issuer may make
available to prospective insureds any of the other Medicare
supplement insurance benefit plans in addition to the basic core
package, but not in lieu of it. However, the benefits described in
paragraphs (6) and (7) shall not be offered so long as California is
required to disallow these benefits for Medicare beneficiaries by the
Centers for Medicare and Medicaid Services or other agent of the
federal government under Section 1395ss of Title 42 of the United
States Code.
(1) Coverage of Part A Medicare eligible expenses for
hospitalization to the extent not covered by Medicare from the 61st
day to the 90th day, inclusive, in any Medicare benefit period.
(2) Coverage of Part A Medicare eligible expenses incurred for
hospitalization to the extent not covered by Medicare for each
Medicare lifetime inpatient reserve day used.
(3) 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
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.
(4) Coverage under Medicare Parts A and 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.
(5) Coverage for the coinsurance amount, or in the case of
hospital outpatient department services, the copayment amount, of
Medicare eligible expenses under Part B regardless of hospital
confinement, subject to the Medicare Part B deductible.
(6) Coverage of the actual cost, up to the legally billed amount,
of an annual mammogram as provided in Section 10123.81, to the extent
not paid by Medicare.
(7) Coverage of the actual cost, up to the legally billed amount,
of an annual cervical cancer screening test as provided in Section
10123.18, to the extent not paid by Medicare.
(c) The following additional benefits shall be included in
Medicare supplement benefit plans B to J, inclusive, only as provided
by Section 10192.9.
(1) With respect to the Medicare Part A deductible, coverage for
all of the Medicare Part A inpatient hospital deductible amount per
benefit period.
(2) With respect to skilled nursing facility care, coverage for
the actual billed charges up to the coinsurance amount from the 21st
day to the 100th day, inclusive, in a Medicare benefit period for
posthospital skilled nursing facility care eligible under Medicare
Part A.
(3) With respect to the Medicare Part B deductible, coverage for
all of the Medicare Part B deductible amount per calendar year
regardless of hospital confinement.
(4) With respect to 80 percent of the Medicare Part B excess
charges, coverage for 80 percent of the difference between the actual
Medicare Part B charge as billed, not to exceed any charge
limitation established by the Medicare Program or state law, and the
Medicare-approved Part B charge. If the insurer limits payment to a
limiting charge, the insurer has the burden to establish that amount
as the legal limit.
(5) With respect to 100 percent of the Medicare Part B excess
charges, coverage for all of the difference between the actual
Medicare Part B charge as billed, not to exceed any charge limitation
established by the Medicare Program or state law, and the
Medicare-approved Part B charge. If the insurer limits payment to a
limiting charge, the insurer has the burden to establish that amount
as the legal limit.
(6) With respect to the basic outpatient prescription drug
benefit, coverage for 50 percent of outpatient prescription drug
charges, after a two hundred fifty dollar ($250) calendar year
deductible, to a maximum of one thousand two hundred fifty dollars
($1,250) in benefits received by the insured per calendar year, to
the extent not covered by Medicare. On and after January 1, 2006, no
Medicare supplement policy may be sold or issued if it includes a
prescription drug benefit.
(7) With respect to the extended outpatient prescription drug
benefit, coverage for 50 percent of outpatient prescription drug
charges, after a two hundred fifty dollar ($250) calendar year
deductible, to a maximum of three thousand dollars ($3,000) in
benefits received by the insured per calendar year, to the extent not
covered by Medicare. On and after January 1, 2006, no Medicare
supplement policy may be sold or issued if it includes a prescription
drug benefit.
(8) With respect to medically necessary emergency care in a
foreign country, coverage to the extent not covered by Medicare for
80 percent of the billed charges for Medicare-eligible expenses for
medically necessary emergency hospital, physician, and medical care
received in a foreign country, which care would have been covered by
Medicare if provided in the United States and which care began during
the first 60 consecutive days of each trip outside the United
States, subject to a calendar year deductible of two hundred fifty
dollars ($250), and a lifetime maximum benefit of fifty thousand
dollars ($50,000). For purposes of this benefit, "emergency care"
shall mean care needed immediately because of an injury or an illness
of sudden and unexpected onset.
(9) With respect to the following, reimbursement shall be for the
actual charges up to 100 percent of the Medicare-approved amount for
each service, as if Medicare were to cover the service as identified
in American Medical Association Current Procedural Terminology (AMA
CPT) codes, up to a maximum of one hundred twenty dollars ($120)
annually under this benefit, however, this benefit shall not include
payment for any procedure covered by Medicare:
(A) An annual clinical preventive medical history and physical
examination that may include tests and services from subparagraph (B)
and patient education to address preventive health care measures.
(B) The following screening tests or preventive services that are
not covered by Medicare, the selection and frequency of which are
determined to be medically appropriate by the attending physician:
(i) Fecal occult blood test.
(ii) Mammogram.
(C) Influenza vaccine administered at any appropriate time during
the year.
(10) With respect to the at-home recovery benefit, coverage for
the actual charges up to forty dollars ($40) per visit and an annual
maximum of one thousand six hundred dollars ($1,600) per year to
provide short-term, at-home assistance with activities of daily
living for those recovering from an illness, injury, or surgery.
(A) For purposes of this benefit, the following definitions shall
apply:
(i) "Activities of daily living" include, but are not limited to,
bathing, dressing, personal hygiene, transferring, eating,
ambulating, assistance with drugs that are normally
self-administered, and changing bandages or other dressings.
(ii) "Care provider" means a duly qualified or licensed home
health aide or homemaker, or a personal care aide or nurse provided
through a licensed home health care agency or referred by a licensed
referral agency or licensed nurses registry.
(iii) "Home" shall mean any place used by the insured as a place
of residence, provided that the place would qualify as a residence
for home health care services covered by Medicare. A hospital or
skilled nursing facility shall not be considered the insured's place
of residence.
(iv) "At-home recovery visit" means the period of a visit required
to provide at-home recovery care, without any limit on the duration
of the visit, except that each consecutive four hours in a 24-hour
period of services provided by a care provider is one visit.
(B) With respect to coverage requirements and limitations, the
following shall apply:
(i) At-home recovery services provided shall be primarily services
that assist in activities of daily living.
(ii) The insured's attending physician shall certify that the
specific type and frequency of at-home recovery services are
necessary because of a condition for which a home care plan of
treatment was approved by Medicare.
(iii) Coverage is limited to the following:
(I) No more than the number and type of at-home recovery visits
certified as necessary by the insured's attending physician. The
total number of at-home recovery visits shall not exceed the number
of Medicare-approved home health care visits under a
Medicare-approved home care plan of treatment.
(II) The actual charges for each visit up to a maximum
reimbursement of forty dollars ($40) per visit.
(III) One thousand six hundred dollars ($1,600) per calendar year.
(IV) Seven visits in any one week.
(V) Care furnished on a visiting basis in the insured's home.
(VI) Services provided by a care provider as defined in
subparagraph (A).
(VII) At-home recovery visits while the insured is covered under
the policy or certificate and not otherwise excluded.
(VIII) At-home recovery visits received during the period the
insured is receiving Medicare-approved home care services or no more
than eight weeks after the service date of the last Medicare-approved
home health care visit.
(C) Coverage is excluded for the following:
(i) Home care visits paid for by Medicare or other government
programs.
(ii) Care provided by family members, unpaid volunteers, or
providers who are not care providers.
(d) The standardized Medicare supplement benefit plan "K" shall
consist of the following benefits:
(1) Coverage of 100 percent of the Medicare Part A hospital
coinsurance amount for each day used from the 61st to the 90th day,
inclusive, in any Medicare benefit period.
(2) Coverage of 100 percent of the Medicare Part A hospital
coinsurance amount for each Medicare lifetime inpatient reserve day
used from the 91st to the 150th day, inclusive, in any Medicare
benefit period.
(3) 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 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 for this benefit as payment in full and shall not bill the
insured for any balance.
(4) With respect to the 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
described in paragraph (10) is met.
(5) With respect to skilled nursing facility care, coverage for 50
percent of the coinsurance amount for each day used from the 21st
day to the 100th day, inclusive, in a Medicare benefit period for
posthospital skilled nursing facility care eligible under Medicare
Part A until the out-of-pocket limitation described in paragraph (10)
is met.
(6) With respect to hospice care, coverage for 50 percent of cost
sharing for all Medicare Part A eligible expenses and respite care
until the out-of-pocket limitation described in paragraph (10) is
met.
(7) 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 described in paragraph (10) is
met.
(8) Except for coverage provided in paragraph (9), 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 (10).
(9) Coverage of 100 percent of the cost sharing for Medicare Part
B preventive services, after the policyholder pays the Medicare Part
B deductible.
(10) 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 four thousand dollars
($4,000) in 2006, indexed each year by the appropriate inflation
adjustment specified by the secretary.
(e) The standardized Medicare supplement benefit plan "L" shall
consist of the following benefits:
(1) The benefits described in paragraphs (1), (2), (3), and (9) of
subdivision (d).
(2) With respect to the Medicare Part A deductible, coverage for
75 percent of the Medicare Part A inpatient hospital deductible
amount per benefit period until the out-of-pocket limitation
described in paragraph (8) is met.
(3) With respect to skilled nursing facility care, coverage for 75
percent of the coinsurance amount for each day used from the 21st
day to the 100th day, inclusive, in a Medicare benefit period for
posthospital skilled nursing facility care eligible under Medicare
Part A until the out-of-pocket limitation described in paragraph (8)
is met.
(4) With respect to hospice care, coverage for 75 percent of cost
sharing for all Medicare Part A eligible expenses and respite care
until the out-of-pocket limitation described in paragraph (8) is met.
(5) Coverage for 75 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 described in paragraph (8) is met.
(6) Except for coverage provided in paragraph (7), coverage for 75
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 described in paragraph (8) is met.
(7) Coverage for 100 percent of the cost sharing for Medicare Part
B preventive services after the policyholder pays the Part B
deductible.
(8) Coverage of 100 percent of the cost sharing for 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 two thousand dollars ($2,000) in 2006,
indexed each year by the appropriate inflation adjustment specified
by the secretary.
(f) An issuer shall prominently indicate through text edits, or by
other means acceptable to the commissioner, an amendment made to a
Medicare supplement policy form that the department previously
approved on the basis that the amendment is consistent with this
section. The department may, in its discretion, restrict its review
to amendments made to Medicare supplement policy forms that have not
previously been found consistent with this section in order to
facilitate the availability of amended policy forms that are
consistent with the federal Medicare Modernization Act. The
department shall not restrict its review if the amendment makes
additional changes to the Medicare supplement policy form.
10192.81. The following standards are applicable to all Medicare
supplement policies or certificates delivered or issued for delivery
in this state with an effective date 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 on or after June 1, 2010.
Benefit standards applicable to Medicare supplement policies and
certificates issued with an effective date prior to June 1, 2010,
remain subject to the requirements of Section 10192.8.
(a) The following general standards apply to Medicare supplement
policies and certificates and are in addition to all other
requirements of this article:
(1) A Medicare supplement policy or certificate shall not exclude
or limit benefits for losses incurred more than six months from the
effective date of coverage because it involved a preexisting
condition. The policy or certificate shall not define a preexisting
condition more restrictively than a condition for which medical
advice was given or treatment was recommended by or received from a
physician within six months before the effective date of coverage.
(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 modified to correspond with those changes.
(4) A Medicare supplement policy or certificate shall not provide
for termination of coverage of a spouse solely because of the
occurrence of an event specified for termination of coverage of the
insured, other than the nonpayment of premium.
(5) Each Medicare supplement policy shall be guaranteed renewable.
(A) The issuer shall not cancel or nonrenew the policy solely on
the ground of health status of the individual.
(B) The issuer shall not cancel or nonrenew the policy for any
reason other than nonpayment of premium or material misrepresentation
which is shown by the issuer to be material to the acceptance for
coverage. The contestability period for Medicare supplement insurance
shall be two years, pursuant to Section 10350.2.
(C) If the Medicare supplement policy is terminated by the master
policyholder and is not replaced as provided under subparagraph (E),
the issuer shall offer certificate holders an individual Medicare
supplement policy which, at the option of the certificate holder,
does one of the following:
(i) Provides for continuation of the benefits contained in the
group policy.
(ii) Provides for benefits that otherwise meet the requirements of
one of the standardized policies defined in this article.
(D) If an individual is a certificate holder in a group Medicare
supplement policy and the individual terminates membership in the
group, the issuer shall do one of the following:
(i) Offer the certificate holder the conversion opportunity
described in subparagraph (C).
(ii) At the option of the group policyholder, offer the
certificate holder continuation of coverage under the group policy.
(E) (i) If a group Medicare supplement policy is replaced by
another group Medicare supplement policy purchased by the same
policyholder, the issuer of the replacement policy shall offer
coverage to all persons covered under the old group policy on its
date of termination. Coverage under the new policy shall not result
in any exclusion for preexisting conditions that would have been
covered under the group policy being replaced.
(ii) If a Medicare supplement policy or certificate replaces
another Medicare supplement policy or certificate that has been in
force for six months or more, the replacing issuer shall not impose
an exclusion or limitation based on a preexisting condition. If the
original coverage has been in force for less than six months, the
replacing issuer shall waive any time period applicable to
preexisting conditions, waiting periods, elimination periods, or
probationary periods in the new policy or certificate to the extent
the time was spent under the original coverage.
(6) Termination of a Medicare supplement policy or certificate
shall be without prejudice to any continuous loss that commenced
while the policy 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 insured, limited to the
duration of the policy benefit period, if any, or payment of the
maximum benefits. Receipt of Medicare Part D benefits shall not be
considered in determining a continuous loss.
(7) (A) (i) A Medicare supplement policy or certificate shall
provide that benefits and premiums under the policy or certificate
shall be suspended at the request of the policyholder or certificate
holder for the period, not to exceed 24 months, in which the
policyholder or certificate holder has applied for and is determined
to be entitled to medical assistance under Medi-Cal, but only if the
policyholder or certificate holder notifies the issuer of the policy
or certificate within 90 days after the date the individual becomes
entitled to assistance. Upon receipt of timely notice, the insurer
shall return directly to the insured that portion of the premium
attributable to the period of Medi-Cal eligibility, subject to
adjustment for paid claims.
(ii) If suspension occurs and if the policyholder or certificate
holder loses entitlement to medical assistance under Medi-Cal, the
policy or certificate shall be automatically reinstituted (effective
as of the date of termination of entitlement) as of the termination
of entitlement if the policyholder or certificate holder provides
notice of loss of entitlement within 90 days after the date of loss
and pays the premium attributable to the period, effective as of the
date of termination of entitlement or equivalent coverage shall be
provided if the prior form is no longer available.
(iii) Each Medicare supplement policy shall provide that benefits
and premiums under the policy shall be suspended (for any period that
may be provided by federal regulation) at the request of the
policyholder if the policyholder is entitled to benefits under
Section 226(b) of the federal Social Security Act and is covered
under a group health plan (as defined in Section 1862(b)(1)(A)(v) of
the federal Social Security Act). If suspension occurs and if the
policyholder or certificate holder loses coverage under the group
health plan, the policy shall be automatically reinstituted
(effective as of the date of loss of coverage) if the policyholder
provides notice of loss of coverage within 90 days after the date of
the loss and pays the applicable premium.
(B) Reinstitution of coverages shall comply with all of the
following requirements:
(i) Not provide for any waiting period with respect to treatment
of preexisting conditions.
(ii) Provide for resumption of coverage that is substantially
equivalent to coverage in effect before the date of suspension.
(iii) Provide for classification of premiums on terms at least as
favorable to the policyholder or certificate holder as the premium
classification terms that would have applied to the policyholder or
certificate holder had the coverage not been suspended.
(8) A Medicare supplement policy shall not limit coverage
exclusively to a single disease or affliction.
(9) A Medicare supplement policy shall provide an examination
period of 30 days after the receipt of the policy by the applicant
for purposes of review, during which time the applicant may return
the policy as described in subdivision (e) of Section 10192.17.
(b) With respect to the standards for basic (core) benefits for
benefit plans A, B, C, D, F, high deductible F, G, M, and N, every
issuer of Medicare supplement insurance benefit plans shall make
available a policy or certificate including only the following basic
"core" package of benefits to each prospective insured. An issuer may
make available to prospective insureds any of the other Medicare
Supplement Insurance Benefit Plans in addition to the basic (core)
package, but not in lieu of it. However, the benefits described in
paragraphs (7) and (8) shall not be offered so long as California is
required to disallow these benefits for Medicare beneficiaries by the
Centers for Medicare and Medicaid Services or other agent of the
federal government under Section 1395ss of Title 42 of the United
States Code.
(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, inclusive, in any Medicare benefit period.
(2) Coverage of Part A Medicare eligible expenses incurred for
hospitalization to the extent not covered by Medicare for each
Medicare lifetime inpatient reserve day used.
(3) 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.
(4) Coverage under Medicare Parts A and 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.
(5) Coverage for the coinsurance amount, or in the case of
hospital outpatient department services paid under a prospective
payment system, the copayment amount, of Medicare eligible expenses
under Part B regardless of hospital confinement, subject to the
Medicare Part B deductible.
(6) Coverage of cost sharing for all Part A Medicare eligible
hospice care and respite care expenses.
(7) Coverage of the actual cost, up to the legally billed amount,
of an annual mammogram as provided in Section 10123.81, to the extent
not paid by Medicare.
(8) Coverage of the actual cost, up to the legally billed amount,
of an annual cervical cancer screening test as provided in Section
10123.18, to the extent not paid by Medicare.
(c) The following additional benefits shall be included in
Medicare supplement benefit plans B, C, D, F, high deductible F, G,
M, and N, consistent with the plan type and benefits for each plan as
provided in Section 10192.91:
(1) With respect to the Medicare Part A deductible, coverage for
100 percent of the Medicare Part A inpatient hospital deductible
amount per benefit period.
(2) With respect to the Medicare Part A deductible, coverage for
50 percent of the Medicare Part A inpatient hospital deductible
amount per benefit period.
(3) With respect to skilled nursing facility care, coverage for
the actual billed charges up to the coinsurance amount from the 21st
day through the 100th day in a Medicare benefit period for
posthospital skilled nursing facility care eligible under Medicare
Part A.
(4) With respect to the Medicare Part B deductible, coverage for
100 percent of the Medicare Part B deductible amount per calendar
year regardless of hospital confinement.
(5) With respect to 100 percent of the Medicare Part B excess
charges, coverage for all of the difference between the actual
Medicare Part B charges as billed, not to exceed any charge
limitation established by the Medicare Program or state law, and the
Medicare-approved Part B charge.
(6) With respect to medically necessary emergency care in a
foreign country, coverage to the extent not covered by Medicare for
80 percent of the billed charges for Medicare-eligible expenses for
medically necessary emergency hospital, physician, and medical care
received in a foreign country, which care would have been covered by
Medicare if provided in the United States and which care began during
the first 60 consecutive days of each trip outside the United
States, subject to a calendar year deductible of two hundred fifty
dollars ($250), and a lifetime maximum benefit of fifty thousand
dollars ($50,000). For purposes of this benefit, "emergency care"
shall mean care needed immediately because of an injury or an illness
of sudden and unexpected onset.
10192.9. The following standards are applicable to all Medicare
supplement policies or certificates delivered or issued for delivery
in this state on or after July 1, 1992, and with an effective date
prior to June 1, 2010.
(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 subdivision
(b) of Section 10192.8.
(b) 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 by subdivision (f)
and by Section 10192.10.
(c) Benefit plans shall be uniform in structure, language,
designation and format to the standard benefit plans A to L,
inclusive, listed in subdivision (e), and shall conform to the
definitions in Section 10192.4. Each benefit shall be structured in
accordance with the format provided in subdivisions (b), (c), (d),
and (e) of Section 10192.8 and list the benefits in the order listed
in subdivision (e). For purposes of this section, "structure,
language, and format" means style, arrangement, and overall content
of a benefit.
(d) An issuer may use, in addition to the benefit plan
designations required in subdivision (c), other designations to the
extent permitted by law.
(e) With respect to the makeup of benefit plans, the following
shall apply:
(1) Standardized Medicare supplement benefit plan A shall be
limited to the basic (core) benefit common to all benefit plans, as
defined in subdivision (b) of Section 10192.8.
(2) Standardized Medicare supplement benefit plan B shall include
only the following: the core benefit, plus the Medicare Part A
deductible as defined in paragraph (1) of subdivision (c) of Section
10192.8.
(3) Standardized Medicare supplement benefit plan C shall include
only the following: the core benefit, 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 paragraphs (1), (2), (3), and (8) of
subdivision (c) of Section 10192.8, respectively.
(4) Standardized Medicare supplement benefit plan D shall include
only the following: the core benefit, 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 paragraphs (1), (2), (8), and (10) of subdivision (c)
of Section 10192.8, respectively.
(5) Standardized Medicare supplement benefit plan E shall include
only the following: the core benefit, 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 paragraphs (1), (2), (8), and (9) of subdivision (c) of
Section 10192.8, respectively.
(6) Standardized Medicare supplement benefit plan F shall include
only the following: the core benefit, plus the Medicare Part A
deductible, the skilled nursing facility care, the Medicare Part B
deductible, 100 percent of the Medicare Part B excess charges, and
medically necessary emergency care in a foreign country as defined in
paragraphs (1), (2), (3), (5), and (8) of subdivision (c) of Section
10192.8, respectively.
(7) Standardized Medicare supplement benefit high deductible plan
F shall include only the following: 100 percent of covered expenses
following the payment of the annual high deductible plan F
deductible. The covered expenses include the core benefit, plus the
Medicare Part A deductible, skilled nursing facility care, the
Medicare Part B deductible, 100 percent of the Medicare Part B excess
charges, and medically necessary emergency care in a foreign country
as defined in paragraphs (1), (2), (3), (5), and (8) of subdivision
(c) of Section 10192.8, respectively. 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, as adjusted annually thereafter
by the secretary to reflect the change in the Consumer Price Index
for all urban consumers for the 12-month period ending with August of
the preceding year, and rounded to the nearest multiple of ten
dollars ($10).
(8) Standardized Medicare supplement benefit plan G shall include
only the following: the core benefit, plus the Medicare Part A
deductible, skilled nursing facility care, 80 percent of the Medicare
Part B excess charges, medically necessary emergency care in a
foreign country, and the at-home recovery benefit as defined in
paragraphs (1), (2), (4), (8), and (10) of subdivision (c) of Section
10192.8, respectively.
(9) Standardized Medicare supplement benefit plan H shall consist
of only the following: the core benefit, plus the Medicare Part A
deductible, skilled nursing facility care, basic outpatient
prescription drug benefit, and medically necessary emergency care in
a foreign country as defined in paragraphs (1), (2), (6), and (8) of
subdivision (c) of Section 10192.8, respectively. The outpatient
prescription drug benefit shall not be included in a Medicare
supplement policy sold on or after January 1, 2006.
(10) Standardized Medicare supplement benefit plan I shall consist
of only the following: the core benefit, plus the Medicare Part A
deductible, skilled nursing facility care, 100 percent of the
Medicare Part B excess charges, basic outpatient prescription drug
benefit, medically necessary emergency care in a foreign country, and
at-home recovery benefit as defined in paragraphs (1), (2), (5),
(6), (8), and (10) of subdivision (c) of Section 10192.8,
respectively. The outpatient prescription drug benefit shall not be
included in a Medicare supplement policy sold on or after January 1,
2006.
(11) Standardized Medicare supplement benefit plan J shall consist
of only the following: the core benefit, plus the Medicare Part A
deductible, skilled nursing facility care, Medicare Part B
deductible, 100 percent of the Medicare Part B excess charges,
extended outpatient prescription drug benefit, medically necessary
emergency care in a foreign country, preventive medical care, and
at-home recovery benefit as defined in paragraphs (1), (2), (3), (5),
(7), (8), (9), and (10) of subdivision (c) of Section 10192.8,
respectively. The outpatient prescription drug benefit shall not be
included in a Medicare supplement policy sold on or after January 1,
2006.
(12) Standardized Medicare supplement benefit high deductible plan
J shall consist of only the following: 100 percent of covered
expenses following the payment of the annual high deductible plan J
deductible. The covered expenses include the core benefit, plus the
Medicare Part A deductible, skilled nursing facility care, Medicare
Part B deductible, 100 percent of the Medicare Part B excess charges,
extended outpatient prescription drug benefit, medically necessary
emergency care in a foreign country, preventive medical care benefit,
and at-home recovery benefit as defined in paragraphs (1), (2), (3),
(5), (7), (8), (9), and (10) of subdivision (c) of Section 10192.8,
respectively. 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, as adjusted
annually thereafter by the secretary to reflect the change in the
Consumer Price Index for all urban consumers for the 12-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 on
or after January 1, 2006.
(13) Standardized Medicare supplement benefit plan K shall consist
of only those benefits described in subdivision (d) of Section
10192.8.
(14) Standardized Medicare supplement benefit plan L shall consist
of only those benefits described in subdivision (e) of Section
10192.8.
(f) 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, that are not otherwise available and
that are cost-effective and offered in a manner that is consistent
with the goal of simplification of Medicare supplement policies. On
and after January 1, 2006, the innovative benefit shall not include
an outpatient prescription drug benefit.
10192.91. The following standards are applicable to all Medicare
supplement policies or certificates delivered or issued for delivery
in this state with an effective date 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 plan standards.
Benefit plan standards applicable to Medicare supplement policies and
certificates issued with an effective date before June 1, 2010,
remain subject to the requirements of Section 10192.9.
(a) (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 subdivision
(b) of Section 10192.81.
(2) If an issuer makes available any of the additional benefits
described in subdivision (c) of Section 10192.81, or offers
standardized benefit plans K or L, as described in paragraphs (8) and
(9) of subdivision (e), 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 paragraph (1), a policy form or certificate form
containing either standardized benefit plan C, as described in
paragraph (3) of subdivision (e), or standardized benefit plan F, as
described in paragraph (5) of subdivision (e).
(b) 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 subdivision (f)
and by Section 10192.10.
(c) Benefit plans shall be uniform in structure, language,
designation, and format to the standard benefit plans listed in
subdivision (e) and conform to the definitions in Section 10192.4.
Each benefit shall be structured in accordance with the format
provided in subdivisions (b) and (c) of Section 10192.81; or, in the
case of plan K or L, in paragraph (8) or (9) of subdivision (e) and
list the benefits in the order shown in subdivision (e). For purpose
