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§ 3105. Minimum benefit standards

Purdon's Pennsylvania Statutes and Consolidated StatutesTitle 40 P.S. Insurance

Purdon's Pennsylvania Statutes and Consolidated Statutes
Title 40 P.S. Insurance (Refs & Annos)
Chapter 11. Medicare Supplement Insurance
40 P.S. § 3105
§ 3105. Minimum benefit standards
Currentness
No policy shall be filed with the department as a medicare supplement policy unless the policy meets or exceeds, either in a single policy or, in the case of health plan corporations and nonprofit health service plans, in one or more policies issued in conjunction with one another, the requirements of the NAIC Model Regulation to Implement the Individual Accident and Sickness Insurance Minimum Standards Act, as adopted by the National Association of Insurance Commissioners on June 6, 1979 as it applies to medicare supplement policies. At least the following provisions and benefits shall be provided in such policy:
(1) A medicare supplement policy may not exclude losses incurred more than six months from the effective date of coverage for a preexisting condition. The policy may 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 prior to the effective date of coverage.
(2) The term “medicare benefit period” shall mean the unit of time used in the medicare program to measure use of services and availability of benefits under Part A, medical hospital insurance.
(3) The term “medicare eligible expenses” shall mean health care expenses of the kinds covered by medicare to the extent recognized as reasonable by medicare. Payment of benefits by insurers for medicare eligible expenses may be conditioned upon the same or less restrictive payment conditions, including determinations of medical necessity as are applicable to medicare claims.
(4)(i) Coverage shall not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents.
(ii) Coverage shall provide that benefits designed to cover cost sharing amounts under medicare shall be changed automatically to coincide with any changes in the applicable medicare deductible amount and copayment percentage factors. Premiums may be changed to correspond with such changes.
(5) The medicare supplement policy must include:
(i) Coverage of Part A medicare eligible expenses for hospitalization to the extent not covered by medicare from the 61st day through the 90th day in any medicare benefit period.
(ii) Coverage of Part A medicare eligible expenses incurred as daily hospital charges during use of medicare's lifetime hospital inpatient reserve days.
(iii) Upon exhaustion of all medicare hospital inpatient coverage including the lifetime reserve days, coverage of 90% of all medicare Part A eligible expenses for hospitalization not covered by medicare subject to a lifetime maximum benefit of an additional 365 days.
(iv) Coverage of 20% of the amount of medicare eligible expenses under Part B regardless of hospital confinement, subject to a maximum calendar year out-of-pocket deductible of $200 of such expenses and to a maximum benefit of at least $5,000 per calendar year.
(6)(i) Insurers which made available within the Commonwealth of Pennsylvania any medicare supplement policy subject to this act shall also simultaneously offer to the same prospective insured persons an additional benefit plan medicare supplement coverage which both conforms to the terms and conditions of section 41 and which also provides at least the following coverages:
(A) the initial Part A deductible;
(B) skilled nursing home charges incurred in addition to those covered by medicare; and
(C) coverage of 20% of eligible expenses incurred under Part B of medicare in excess of the deductible amount applied to such expenses by medicare.
(ii) Such offer shall be given prominence in any solicitation of the medicare supplement policy benefits described in section 52 and shall provide the prospective insured the opportunity to simultaneously enroll or apply for the additional benefit plan medicare supplement coverage. The description of the additional benefit plan medicare supplement coverage shall include a statement of the coverages, the premium charges, and any additional applicable exclusions and limitations permitted for the additional benefit plan medicare supplement coverage.
(iii) Such additional benefit plan coverage, if elected by the prospective insured person, shall take effect no later than 15 days following the effective date which applies to medicare supplement coverage described in section 5.

Credits

1982, Dec. 15, P.L. 1291, No. 292, § 5, effective July 1, 1983.

Footnotes

1
40 P.S. § 3104.
2
This section.
40 P.S. § 3105, PA ST 40 P.S. § 3105
Current through Act 13 of the 2024 Regular Session. Some statute sections may be more current, see credits for details.
End of Document