054.00.27-17. REQUIRED DISCLOSURE PROVISIONS
AR ADC 054.00.27-17Arkansas Administrative CodeEffective: February 1, 2018
Effective: February 1, 2018
Ark. Admin. Code 054.00.27-17
054.00.27-17. REQUIRED DISCLOSURE PROVISIONS
(1) Medicare supplement policies and certificates shall include a renewal or continuation provision. The language or specifications of the provision shall be consistent with the type of contract issued. The provision shall be appropriately captioned and shall appear on the first page of the policy, and shall include any reservation by the issuer of the right to change premiums.
(2) Except for riders or endorsements by which the issuer effectuates a request made in writing by the insured, exercises a specifically reserved right under a Medicare supplement policy, or is required to reduce or eliminate benefits to avoid duplication of Medicare benefits, all riders or endorsements added to a Medicare supplement policy after date of issue or at reinstatement or renewal which reduce or eliminate benefits or coverage in the policy shall require a signed acceptance by the insured. After the date of policy or certificate issue, any rider or endorsement which increases benefits or coverage with a concomitant increase in premium during the policy term shall be agreed to in writing signed by the insured, unless the benefits are required by the minimum standards for Medicare supplement policies, or if the increased benefits or coverage is required by law. Where a separate additional premium is charged for benefits provided in connection with riders or endorsements, the premium charge shall be set forth in the policy.
(5) Medicare supplement policies and certificates shall have a notice prominently printed on the first page of the policy or certificate or attached thereto stating in substance that the policyholder or certificate holder shall have the right to return the policy or certificate within thirty (30) days of its delivery and to have the premium refunded if, after examination of the policy or certificate, the insured person is not satisfied for any reason.
(6) (a) Issuers of accident and health policies or certificates which provide hospital or medical expense coverage on an expense incurred or indemnity basis to person(s) eligible for Medicare shall provide to those applicants a Guide to Health Insurance for People with Medicare in the form developed jointly by the National Association of Insurance Commissioners and the Centers for Medicare & Medicaid Services (CMS) and in a type size no smaller than 12 point type. Delivery of the Guide shall be made whether or not the policies or certificates are advertised, solicited or issued as Medicare supplement policies or certificates as defined in this rule. Except in the case of direct response issuers, delivery of the Guide shall be made to the applicant at the time of application and acknowledgement of receipt of the Guide shall be obtained by the issuer. Direct response issuers shall deliver the Guide to the applicant upon request, but not later than at the time the policy is delivered.
(1) As soon as practicable, but no later than thirty (30) days prior to the annual effective date of any Medicare benefit changes, an issuer shall notify its policyholders and certificate holders of modifications it has made to Medicare supplement insurance policies or certificates in a format acceptable to the Commissioner. The notice shall:
(2) If an outline of coverage is provided at the time of application and the Medicare supplement policy or certificate is issued on a basis which would require revision of the outline, a substitute outline of coverage properly describing the policy or certificate shall accompany such policy or certificate when it is delivered; and contain the following statement, in no less than twelve (12) point type, immediately above the company name: “NOTICE: Read this outline of coverage carefully. It is not identical to the outline of coverage provided upon application and the coverage originally applied for has not been issued.”
(3) The outline of coverage provided to applicants pursuant to this Section consists of four (4) parts: a cover page, premium information, disclosure pages, and charts displaying the features of each benefit plan offered by the issuer. The outline of coverage shall be in the language and format prescribed below in no less than twelve (12) point type. All plans shall be shown on the cover page, and the plan(s) that are offered by the issuer shall be prominently identified. Premium information for plans that are offered shall be shown on the cover page or immediately following the cover page and shall be prominently displayed. The premium and mode shall be stated for all plans that are offered to the prospective applicant. All possible premiums for the prospective applicant shall be illustrated.
Benefit Chart of Medicare Supplement Coverage-Cover Page: Plans With An Effective Date Of Coverage Prior To June 1, 2010
[COMPANY NAME]
Outline of Medicare Supplement Coverage-Cover Page:_____
Benefit Plan(s) __________ [insert letter(s) of plan(s) being offered]
These charts show the benefits included in each of the standard Medicare supplement plans. Every company must make available Plan “A”. Some plans may not be available in your state.
See outlines of coverage sections for details about ALL plans.
Basic Benefits For Plans A -- J:
Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.
Medical Expenses: Part B coinsurance (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services.
Blood: First three pints of blood each year.
A | B | C | D | E | F * | G | H | I | J * |
|---|---|---|---|---|---|---|---|---|---|
Basic Benefits | Basic Benefits | Basic Benefits | Basic Benefits | Basic Benefits | Basic Benefits | Basic Benefits | Basic Benefits | Basic Benefits | Basic Benefits |
Skilled Nursing Co-Insurance | Skilled Nursing Co-Insurance | Skilled Nursing Co-Insurance | Skilled Nursing Co-Insurance | Skilled Nursing Co-Insurance | Skilled Nursing Co-Insurance | Skilled Nursing Co-Insurance | Skilled Nursing Co-Insurance | ||
Part A Deductible | Part A Deductible | Part A Deductible | Part A Deductible | Part A Deductible | Part A Deductible | Part A Deductible | Part A Deductible | Part A Deductible | |
Part B Deductible | Part B Deductible | Part B Deductible | |||||||
Part B Excess (100%) | Part B Excess (80%) | Part B Excess (100%) | Part B Excess (100%) | ||||||
Foreign Travel Emergency | Foreign Travel Emergency | Foreign Travel Emergency | Foreign Travel Emergency | Foreign Travel Emergency | Foreign Travel Emergency | Foreign Travel Emergency | Foreign Travel Emergency | ||
At-Home Recovery | At-Home Recovery | At-Home Recovery | At-Home Recovery | ||||||
[not available after December 31, 2005; so thereafter strike this line] | Basic Drugs ($1,250 Limit) | Basic Drugs ($1,250 Limit) | Extended Drugs ($3,000 Limit) | ||||||
Preventive Care NOT covered by Medicare | Preventive Care NOT covered by Medicare |
* Plans F and J also have an option called a high deductible plan F and a high deductible plan J. These high deductible plans pay the same or offer the same benefits as Plans F and J after one has paid a calendar year [$ __________] deductible. Benefits from high deductible plans F and J will not begin until out-of-pocket expenses are [$ __________]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but does not include, in plan J, the plan's separate prescription drug deductible or, in Plans F and J, the plan's separate foreign travel emergency deductible.
Basic Benefits for Plans K and L include similar services as plans A-J, but cost sharing for the basic benefits is at different levels.
K ** | L ** | |
|---|---|---|
Basic Benefits | 100% of Part A Hospitalization Coinsurance plus coverage for 365 Days after Medicare Benefits End | 100% of Part A Hospitalization Coinsurance plus coverage for 365 Days after Medicare Benefits End |
50% Hospice cost-sharing | 75% Hospice cost-sharing | |
50% of Medicare-eligible expenses for the first three pints of blood | 75% of Medicare-eligible expenses for the first three pints of blood | |
50% Part B Coinsurance, except 100% Coinsurance for Part B Preventive Services | 75% Part B Coinsurance, except 100% Coinsurance for Part B Preventive Services | |
Skilled Nursing Coinsurance | 50% Skilled Nursing Facility Coinsurance | 75% Skilled Nursing Facility Coinsurance |
Part A Deductible | 50% Part A Deductible | 75% Part A Deductible |
Part B Deductible | ||
Part B Excess (100%) | ||
Foreign Travel Emergency | ||
At-Home Recovery | ||
Preventive Care NOT covered by Medicare | ||
$[4000] Out of Pocket Annual Limit *** | $[2000] Out of Pocket Annual Limit *** | |
Once you reach the annual limit, the plan pays 100% of the Medicare copayments, coinsurance, and deductibles for the rest of the calendar year. The out-of-pocket annual limit does NOT include charges from your provider that exceed Medicare-approved amounts, called “Excess Charges”. You will be responsible for paying excess charges. | ||
** Plans K and L provide for different cost-sharing for items and services than Plans A -- J.
*** The out-of-pocket annual limit will increase each year for inflation.
See Outlines of Coverage for details and exceptions.
PREMIUM INFORMATION (Boldface Type)
We [insert issuer's name] can only raise your premium if we raise the premium for all policies like yours in Arkansas.
DISCLOSURES [Boldface Type]
Use this outline to compare benefits and premiums among policies.
READ YOUR POLICY VERY CAREFULLY (Boldface Type)
This is only an outline describing your policy's most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company.
RIGHT TO RETURN POLICY [Boldface Type]
If you find that you are not satisfied with your policy, you may return it to (insert issuer's address]. If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments.
POLICY REPLACEMENT [Boldface Type]
If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it.
NOTICE (Boldface Type)
This policy may not fully cover all of your medical costs.
(for agents/producers:]
Neither (insert company's name] nor its agents or producers are connected with Medicare.
[for direct response:)
[insert company's name) is not connected with Medicare.
This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult “The Medicare Handbook” for more details.
COMPLETE ANSWERS ARE VERY IMPORTANT [Boldface Type]
When you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information. (If the policy or certificate is guaranteed-issue, this paragraph need not appear.)
Review the application carefully before you sign it. Be certain that all information has been properly recorded.
[Include for each plan prominently identified in the cover page, a chart showing the services, Medicare payments, plan payments and insured payments for each plan, using the same language, in the same order, using uniform layout and format as shown in the charts below. No more than four (4) plans may be shown on one (1) chart. For purposes of illustration, charts for each plan are included in this rule. An issuer may use additional benefit plan designations on these charts pursuant to Section 9(D) of this rule.]
[Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the Commissioner.]
Benefit Chart of Medicare Supplement Plans Sold with an effective date of coverage on or After June 1, 2010
This chart shows the benefits included in each of the standard Medicare supplement plans. Every company must make Plan “A” available. Some plans may not be available in your state.
Plans E, H, I, and J are no longer available for sale. [This sentence shall not appear after June 1, 2011.]
Basic Benefits:
• Hospitalization --Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.
• Medical Expenses --Part B coinsurance (generally 20% of Medicare-approved expenses) or co-payments for hospital outpatient services. Plans K, L and N require insureds to pay a portion of Part B coinsurance or co-payments.
• Blood --First three pints of blood each year.
• Hospice-- Part A coinsurance
A | B | C | D | F * | G | K | L | M | N |
|---|---|---|---|---|---|---|---|---|---|
Basic, including 100% Part B coinsurance | Basic, including 100% Part B coinsurance | Basic, including 100% Part B coinsurance | Basic, including 100% Part B coinsurance | Basic, including 100% Part B coinsurance * | Basic, including 100% Part B coinsurance | Hospitalization and preventive care paid at 100%; other basic benefits paid at 50% | Hospitalization and preventive care paid at 100%; other basic benefits paid at 75% | Basic, including 100% Part B coinsurance | Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER |
Skilled Nursing Facility Coinsurance | Skilled Nursing Facility Coinsurance | Skilled Nursing Facility Coinsurance | Skilled Nursing Facility Coinsurance | 50% Skilled Nursing Facility Coinsurance | 75% Skilled Nursing Facility Coinsurance | Skilled Nursing Facility Coinsurance | Skilled Nursing Facility Coinsurance | ||
Part A Deductible | Part A Deductible | Part A Deductible | Part A Deductible | Part A Deductible | 50% Part A Deductible | 75% Part A Deductible | 50% Part A Deductible | Part A Deductible | |
Part B Deductible | Part B Deductible | ||||||||
Part B Excess (100%) | Part B Excess (100%) | ||||||||
Foreign Travel Emergency | Foreign Travel Emergency | Foreign Travel Emergency | Foreign Travel Emergency | Foreign Travel Emergency | Foreign Travel Emergency | ||||
Out-of-pocket limit $[4620]; paid at 100% after limit reached | Out-of-pocket limit $[2310]; paid at 100% after limit reached |
* Plan F also has an option called a high deductible plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year [$2000] deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses exceed [$2000]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan's separate foreign travel emergency deductible.
PREMIUM INFORMATION [Boldface Type]
We [insert issuer's name] can only raise your premium if we raise the premium for all policies like yours in Arkansas.
DISCLOSURES [Boldface Type]
Use this outline to compare benefits and premiums among policies.
This outline shows benefits and premiums of policies sold for effective dates on or after June 1, 2010. Policies sold for effective dates prior to June 1, 2010 have different benefits and premiums. Plans E, H, I, and J are no longer available for sale. [This paragraph shall not appear after June 1, 2011.]
READ YOUR POLICY VERY CAREFULLY [Boldface Type]
This is only an outline describing your policy's most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company.
RIGHT TO RETURN POLICY [Boldface Type]
If you find that you are not satisfied with your policy, you may return it to [insert issuer's address]. If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments.
POLICY REPLACEMENT [Boldface Type]
If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it.
NOTICE [Boldface Type]
This policy may not fully cover all of your medical costs.
[for agents:]
Neither [insert company's name] nor its agents are connected with Medicare.
[for direct response:]
[insert company's name] is not connected with Medicare.
This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult Medicare and You for more details.
COMPLETE ANSWERS ARE VERY IMPORTANT [Boldface Type]
When you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information. [If the policy or certificate is guaranteed issue, this paragraph need not appear.]
Review the application carefully before you sign it. Be certain that all information has been properly recorded.
[Include for each plan prominently identified in the cover page, a chart showing the services, Medicare payments, plan payments and insured payments for each plan, using the same language, in the same order, using uniform layout and format as shown in the charts below. No more than four plans may be shown on one chart. For purposes of illustration, charts for each plan are included in this rule. An issuer may use additional benefit plan designations on these charts pursuant to Section 9.1D of this rule.]
[Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the Commissioner.]
Benefit Chart of Medicare Supplement Plans Sold on or after January 1, 2020
This chart shows the benefits included in each of the standard Medicare supplement plans. Some plans may not be available. Only applicants first eligible for Medicare before 2020 may purchase Plans C, F, and high deductible F.
Note: A √ means 100% of the benefit is paid.
Benefits | Plans Available to All Applicants | Medicare first eligible before 2020 only | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
A | B | D | G 1 | K | L | M | N | C | F 1 | |
Medicare Part A coinsurance and hospital coverage (up to an additional 365 days after Medicare benefits are used up) | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ |
Medicare Part B coinsurance or Copayment | √ | √ | √ | √ | 50% | 75% | √ | √ copays apply 3 | √ | √ |
Blood (first three pints) | √ | √ | √ | √ | 50% | 75% | √ | √ | √ | √ |
Part A hospice care coinsurance or copayment | √ | √ | √ | √ | 50% | 75% | √ | √ | √ | √ |
Skilled nursing facility coinsurance | √ | √ | 50% | 75% | √ | √ | √ | √ | ||
Medicare Part A deductible | √ | √ | √ | 50% | 75% | 50% | √ | √ | √ | |
Medicare Part B deductible | √ | √ | ||||||||
Medicare Part B excess charges | √ | √ | ||||||||
Foreign travel emergency (up to plan limits) | √ | √ | √ | √ | √ | √ | ||||
Out-of-pocket limit in [2017] 2 | $[5,120] 2 | $[2,560] 2 | ||||||||
1 Plans F and G also have a high deductible option which require first paying a plan deductible of $[2200] before the plan begins to pay. Once the plan deductible is met, the plan pays 100% of covered services for the rest of the calendar year. High deductible plan G does not cover the Medicare Part B deductible. However, high deductible plans F and G count your payment of the Medicare Part B deductible toward meeting the plan deductible.
2 Plans K and L pay 100% of covered services for the rest of the calendar year once you meet the out-of-pocket yearly limit.
3 Plan N pays 100% of the Part B coinsurance, except for a co-payment of up to $20 for some office visits and up to a $50 co-payment for emergency room visits that do not result in an inpatient admission.
(1) Any accident and health insurance policy or certificate, other than a Medicare supplement policy; or a policy issued pursuant to a contract under Section 1876 of the Federal Social Security Act (42 U.S.C. 1395 et seq.), disability income policy; or other policy identified in Section 3(B) of this rule, issued for delivery in Arkansas to persons eligible for Medicare shall notify insureds under the policy that the policy is not a Medicare supplement policy or certificate. The notice shall either be printed or attached to the first page of the outline of coverage delivered to insureds under the policy, or if no outline of coverage is delivered, to the first page of the policy, or certificate delivered to insureds. The notice shall be in no less than twelve (12) point type and shall contain the following language:
*THIS (POLICY OR CERTIFICATE] IS NOT A MEDICARE SUPPLEMENT [POLICY OR CONTRACT]. If you are eligible for Medicare, review the Choosing a Medigap Policy: a Guide to Health Insurance for People with Medicare, available from the company.”
(2) Applications provided to persons eligible for Medicare for the health insurance policies or certificates described in Subsection D(1) shall disclose, using the applicable statement in Appendix C, the extent to which the policy duplicates Medicare. The disclosure statement shall be provided as a part of, or together with, the application for the policy or certificate.
Credits
Amended July 1, 2009; Feb. 1, 2018.
Current with amendments received through February 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 054.00.27-17, AR ADC 054.00.27-17
| End of Document |