11 CRR-NY 58.4NY-CRR
STATE COMPILATION OF CODES, RULES AND REGULATIONS OF THE STATE OF NEW YORK
TITLE 11. INSURANCE
CHAPTER III. POLICY AND CERTIFICATE PROVISIONS
SUBCHAPTER A. LIFE, ACCIDENT AND HEALTH INSURANCE
PART 58. MINIMUM STANDARDS FOR FORM, CONTENT AND SALE OF MEDICARE SUPPLEMENT AND MEDICARE SELECT INSURANCE, INCLUDING STANDARDS OF FULL AND FAIR DISCLOSURE
11 CRR-NY 58.4
11 CRR-NY 58.4
58.4 Rules relating to content of forms for Medicare supplement insurance policies and certificates issued with an effective date for coverage on or after June 1, 2010.
(a) General applicability.
The following shall be applicable to Medicare supplement insurance and Medicare select as defined in section 52.11 and 52.14 of this Title, respectively, and shall be in addition to other requirements of this Part. Such rules shall apply to all Medicare supplement and Medicare select policies and certificates issued with an effective date for coverage on or after June 1, 2010 in this State. 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 for coverage prior to June 1, 2010 remain subject to the requirements of section 58.2 of this Part.
(b) Standard Medicare supplement benefit plans issued with an effective date for coverage on or after June 1, 2010.
(1) 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 subparagraph (6)(vii) of this subdivision.
(2) Where a nonprofit health service, hospital service or medical expense indemnity corporation issues a subscriber contract which does not include all of the benefits required for a plan of Medicare supplement insurance, such contract must, in order to qualify as Medicare supplement insurance, be issued in conjunction with another contract including the remainder of the benefits required for a plan of Medicare supplement insurance as prescribed in this section. In the alternative, two or more of such corporations may act jointly and issue a single contract which contains all of the benefits required for a plan of Medicare supplement insurance.
(3) Benefit plans shall be uniform in structure, language, designation and format to the standard benefit plans "A", "B", "C", "D", "F", high deductible “F+”, "G", high deductible “G+”, "K", "L", "M", and "N'' listed in subdivision (c) of this section and conform to the definitions in section 58.1(a) of this Part. Each benefit plan shall be structured in accordance with the format provided in paragraphs (5) and (6) of this subdivision and list the benefits in the order shown in subdivision (c) of this section. For purposes of this section, structure, language, and format means style, arrangement and overall content of a benefit.
(4) An issuer may use, in addition to the benefit plan designations required in paragraph (3) of this subdivision, other designations to the extent permitted by law or regulation.
(5) Standards for Basic “Core” Benefits Common to Medicare Supplement Insurance Benefit Plans "A", "B", "C", "D", "F”, high deductible “F+”, "G", high deductible “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.
(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 for hospitalization to the extent not covered by Medicare for each Medicare lifetime inpatient reserve day used.
(iii) Upon exhaustion of Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 100 percent of the costs incurred for hospitalization expenses of the kind covered by Medicare and recognized as medically necessary by Medicare, subject to a lifetime maximum benefit of an additional 365 days. The issuer may enter into reimbursement contracts with provider hospitals to stand in the place of Medicare and to make payment for the hospitalization expenses at the applicable prospective payment system (PPS) rate or other appropriate Medicare standard of payment, so long as there continues to be no cost to the insured person.
(iv) 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.
(v) 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.
(vi) Hospice care. Coverage of cost sharing for all Part A Medicare eligible hospice care and respite care expenses.
(6) Standards for additional benefits. The following additional benefits shall be included in Medicare supplement benefit Plans "B," "C," "D," "F," high deductible “F+”, "G," high deductible “G+”, "M" and "N" as provided by subdivision (c) of this section.
(i) Medicare Part A deductible. Coverage for 100 percent of the Medicare Part A inpatient hospital deductible amount per benefit period.
(ii) Medicare Part A deductible. Coverage for 50 percent of the Medicare Part A inpatient hospital deductible amount per benefit period.
(iii) 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 post-hospital skilled nursing facility care eligible under Medicare Part A.
(iv) Medicare Part B deductible. Coverage for 100 percent of the Medicare Part B deductible amount per calendar year regardless of hospital confinement.
(v) 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.
(vi) 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 $250, and a lifetime maximum benefit of $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.
(vii) New or innovative benefits. An issuer may, with the prior approval of the superintendent, offer policies or certificates with new or innovative benefits, in addition to the standardized benefits provided in a policy or certificate that otherwise complies with the applicable standards. The new or innovative benefits shall include only benefits that are appropriate to Medicare supplement insurance, are new or innovative, are not otherwise available, and are cost-effective. Approval of new or innovative benefits must not adversely impact the goal of Medicare supplement simplification. New or innovative benefits shall not include an outpatient prescription drug benefit. New or innovative benefits shall not be used to change or reduce benefits, including a change of any cost-sharing provision, in any standardized plan.
(7)
(i) Every issuer shall make available both standardized Medicare supplement insurance benefit plans "A'' and "B,'' as defined in paragraphs (c)(1) and (2) of this section, to each prospective policyholder and certificateholder.
(ii) The issuer shall make available to those individuals who first become eligible for Medicare before January 1, 2020 based on age or disability standardized Medicare supplement benefit plans “C”, as described in paragraph (c)(3) of this section, or “F” as described in paragraph (c)(5) of this section. An issuer may make available to prospective policyholders and certificateholders any of the other Medicare supplement insurance benefit plans permitted by this section in addition to benefit plans “A” and “B”.
(iii) The issuer shall make available to those individuals who first become eligible for Medicare due to age or disability on or after January 1, 2020 standardized Medicare supplement benefit plans “D”, as described in paragraph (c)(4) of this section or “G” as described in paragraph (c)(7) of this section. An issuer may make available to prospective policyholders and certificateholders any of the other Medicare supplement insurance benefit plans permitted by this section in addition to benefit plans “A” and “B” and either “D” or “G”, but not in lieu thereof.
(iv) Every issuer shall permit its policyholders and certificateholders to terminate existing coverage and replace it with any other Medicare supplement insurance benefit plan then being made available to prospective policyholders and certificateholders by the issuer. An issuer may limit changes in coverage initiated by a policyholder or certificateholder to an anniversary date or other regular interval, so long as the interval is not less than every 12 months.
(c) Make-up of Medicare supplement benefit plans issued with an effective date for coverage on or after June 1, 2010.
(1) Standardized Medicare supplement benefit plan "A" shall include only the following: the basic core benefits as defined in paragraph (b)(5) of this section.
(2) Standardized Medicare supplement benefit plan "B" shall include only the following: the core benefits as defined in paragraph (b)(5) of this section, plus 100 percent of the Medicare Part A deductible as defined in subparagraph (b)(6)(i) of this section.
(3) Standardized Medicare supplement benefit plan "C" shall include only the following: the core benefits as defined in paragraph (b)(5) of this section, plus 100 percent of the Medicare Part A deductible, skilled nursing facility care, 100 percent of the Medicare Part B deductible, and medically necessary emergency care in a foreign country as each is defined in subparagraphs (b)(6)(i), (iii), and (vii) of this section.
(4) Standardized Medicare supplement benefit plan "D" shall include only the following: the core benefits as defined in paragraph (b)(5) of this section, plus 100 percent of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as each is defined in subparagraphs (b)(6)(i), (iii), and (vi) of this section.
(5) Standardized Medicare supplement plan "F" shall include only the following: the core benefits as defined in paragraph (b)(5) of this section, plus 100 percent of the Medicare Part A deductible, the skilled nursing facility care, 100 percent of the Medicare Part B deductible, 100 percent of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as each is defined in subparagraphs (b)(6)(i), (iii), (iv), (v) and (vi) of this section.
(6) Standardized Medicare supplement benefit high deductible plan "F+" shall include only the following: 100 percent of covered expenses following payment of the annual high deductible plan "F+" deductible, the core benefits as defined in paragraph (b)(5) of this section, plus 100 percent of the Medicare Part A deductible, skilled nursing facility care, 100 percent of the Medicare Part B deductible, 100 percent of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as each is defined in subparagraphs (b)(6)(i), (iii), (iv), (v), and (vi) of this section. The annual deductible for Medicare supplement benefit high deductible plan "F+" shall consist of out-of-pocket expenses, other than premiums, for services covered by plan "F," and shall be in addition to any other specific benefit deductibles. The basis for the deductible shall be $1,500 and shall be adjusted annually from 1999 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 $10. For example, the annual deductible for Medicare supplement benefit high deductible plan "F+" for 2019 is $2,300.
(7) Standardized Medicare supplement benefit plan "G" shall include only the following: the core benefits as defined in paragraph (b)(5) of this section, plus 100 percent of the Medicare Part A deductible, skilled nursing facility care, 100 percent of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in subparagraphs (b)(6)(i), (iii), (v), and (vi) of this section.
(8) Standardized Medicare supplement benefit high deductible plan “G+” shall include only the following: 100 percent of the covered expenses following payment of the annual high deductible Plan G+ deductible, the core benefits as defined in subdivision (b)(5) of this section, plus 100 percent of the Medicare part A deductible, skilled nursing facility care, 100 percent of the Medicare part B excess charges, and medically necessary emergency care in a foreign country as defined in subparagraph (b)(6)(i), (iii), (v), and (vi) of this section. The annual deductible for Medicare supplement benefit high deductible plan “G+” shall consist of out-of-pocket expenses, other than premiums, for services covered by plan “G”, and shall be in addition to any other specific benefit deductibles. The Medicare part B deductible paid by the beneficiary shall be considered an out-of-pocket expense in meeting the annual high deductible. The basis for the deductible shall be $1,500 and shall be adjusted annually from 1999 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 $10.
(9) Standardized Medicare supplement plan "K" is mandated by The Medicare Prescription Drug, Improvement and Modernization Act of 2003, and shall include only the following:
(i) Part A hospital coinsurance 61st through 90th days. Coverage of 100 percent of the Part A hospital coinsurance amount for each day used from the 61st through the 90th day in any Medicare benefit period;
(ii) Part A hospital coinsurance, 91st through 150th days. Coverage of 100 percent of the Part A hospital coinsurance amount for each Medicare lifetime inpatient reserve day used from the 91st through the 150th day in any Medicare benefit period;
(iii) Part A hospitalization after lifetime reserve days are exhausted. Upon exhaustion of Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 100 percent of the costs incurred for hospitalization expenses of the kind covered by Medicare and recognized as medically necessary by Medicare, subject to a lifetime maximum benefit of an additional 365 days. The issuer may enter into reimbursement contracts with provider hospitals to stand in the place of Medicare and to make payment for the hospitalization expenses at the applicable prospective payment system (PPS) rate or other appropriate Medicare standard of payment, so long as there continues to be no cost to the insured person;
(iv) 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 is met as described in subparagraph (x) of this paragraph;
(v) skilled nursing facility care. Coverage for 50 percent of the coinsurance amount for each day used from the 21st day through the 100th day in a Medicare benefit period for post-hospital skilled nursing facility care eligible under Medicare Part A until the out-of-pocket limitation is met as described in subparagraph (x) of this paragraph;
(vi) hospice care. Coverage for 50 percent of cost sharing for all Part A Medicare eligible expenses and respite care until the out-of-pocket limitation is met as described in subparagraph (x) of this paragraph;
(vii) blood. 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 is met as described in subparagraph (x) of this paragraph;
(viii) Part B cost sharing. Except for coverage provided in subparagraph (ix) of this paragraph, 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 subparagraph (x) of this paragraph;
(ix) Part B preventive services. Coverage of 100 percent of the cost sharing for Medicare Part B preventive services after the policyholder pays the Part B deductible; and
(x) cost sharing after out-of-pocket limits. 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 $5,560 in 2019, indexed each year by the appropriate inflation adjustment specified by the secretary.
(10) Standardized Medicare supplement plan "L" is mandated by The Medicare Prescription Drug, Improvement and Modernization Act of 2003, and shall include only the following:
(i) the benefits described in subparagraphs (9)(i), (ii), (iii), and (ix) of this subdivision;
(ii) the benefit described in subparagraphs (9)(iv), (v), (vi), (vii) and (viii) of this subdivision, but substituting 75 percent for 50 percent; and
(iii) the benefit described in subparagraph (9)(x) of this subdivision, but substituting $2,780 for $5,560.
(11) Standardized Medicare supplement plan "M" shall include only the following: the core benefits as defined in paragraph (b)(5) of this section, plus 50 percent of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as each is defined in subparagraphs (b)(6)(ii), (iii), and (vi) of this section.
(11) Standardized Medicare supplement plan "N" shall include only the following: the core benefits as defined in paragraph (b)(5) of this section, plus 100 percent of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as each is defined in subparagraphs (b)(6)(i), (iii), and (vi) of this section, with copayments in the following amounts:
(i) the lesser of $20 or the Medicare Part B coinsurance or copayment for each covered health care provider office visit (including visits to medical specialists); and
(ii) the lesser of $50 or the Medicare Part B coinsurance or copayment for each covered emergency room visit, however, this copayment shall be waived if the insured is admitted to any hospital and the emergency visit is subsequently covered as a Medicare Part A expense.
(d) Attached is an appendix (Appendix 12, infra) that includes the required disclosure statement for policies and certificates meeting definition of section 52.11 or 52.14 of this Title issued with an effective date for coverage on or after June 1, 2010.
11 CRR-NY 58.4
Current through July 31, 2021
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