| |
A copy of the agenda may be obtained by contacting: The Governor and Cabinet Website at http://www.myflorida.com/myflorida/cabinet/mart.html. The agenda should be available approximately one week before the cabinet meeting.
Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 5 days before the workshop/meeting by contacting: Gerry Smith, Office of Insurance Regulation, E-mail: Gerry.Smith@floir.com. If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).
For more information, you may contact: Gerry Smith, Office of Insurance Regulation, E-mail: Gerry.Smith@floir.com.
THE FULL TEXT OF THE PROPOSED RULE IS:
69O-156.003 Definitions.
For purposes of this rule:
(1) through (16) No change.
(17) “Pre-Standardized Medicare supplement benefit plan,” “Pre-Standardized benefit plan” or “Pre-Standardized plan” means a group or individual policy of Medicare supplement insurance issued prior to January 1, 1992.
(18) “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 January 1, 1992, and with an effective date for coverage prior to June 1, 2010.
(19) “2010 Standardized Medicare supplement benefit plan,” “2010 Standardized benefit plan” or “2010 plan” means a group or individual policy of Medicare supplement insurance with an effective date for coverage on or after June 1, 2010.
(20)(17) “Replacement” is any transaction wherein new Medicare supplement insurance is to be purchased and it is known to the agent, broker or insurer at the time of application that, as a part of the transaction, existing accident and health insurance has been or is to be lapsed or the benefits thereof substantially reduced.
(21)(18) “Secretary” means the Secretary of the United States Department of Health and Human Services.
Rulemaking Specific Authority 624.308(1), 627.674(2), 627.6741(5) FS. Law Implemented 624.307(1), 627.674, 627.6741 FS. History– New 1-1-81, Formerly 4-51.03, Amended 11-7-88, 9-4-89, 12-9-90, Formerly 4-51.003, Amended 1-1-92, 7-14-96, 7-26-99, 3-4-01, Formerly 4-156.003, Amended 9-15-05,_________.
69O-156.005 Policy Provisions.
(1) Except for permitted preexisting condition clauses as described in paragraphs 69O-156.006(1)(b), and 69O-156.007(1)(a) and 69O-156.0075(1)(a), F.A.C., of this chapter, no policy or certificate may be advertised, solicited or issued for delivery in this State as a Medicare supplement policy if such policy or certificate contains limitations or exclusions on coverage that are more restrictive than those of Medicare.
(2) through (4) No change.
Rulemaking Specific Authority 624.308(1), 627.674(2) FS. Law Implemented 624.307(1), 627.674(2) FS. History–New 1-1-81, Formerly 4-51.04, Amended 9-4-89, Formerly 4-51.004, Amended 1-1-92, Formerly 4-156.005, Amended 9-15-05,________.
69O-156.006 Minimum Benefit Standards for Pre-Standarized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery Prior to January 1, 1992.
As it relates to Pre-Standarized Medicare Supplement Benefit Plan Policies or certificates issued for delivery prior to January 1, 1992, nNo policy or certificate may be advertised, solicited, issued, delivered or issued for delivery in this State as a Medicare supplement policy or certificate unless it meets or exceeds the following minimum standards. These are minimum standards and do not preclude the inclusion of other provisions or benefits which are not inconsistent with these standards.
(1) General Standards. The following standards apply to Medicare supplement policies and certificates and are in addition to all other requirements of this regulation.
(a) Medicare supplement coverage shall provide at least, but not be limited to, the benefits provided in Section 627.674, F.S.
(b) A Medicare supplement policy or certificate shall not exclude or limit benefits for losses incurred more than six (6) months from the effective date of coverage because it involved a preexisting condition. The policy or certificate 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 (6) months before the effective date of coverage.
(c) A Medicare supplement policy or certificate shall not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents.
(d) 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, amount and copayment, or coinsurance amounts percentage factors. Premiums may be modified to correspond with such changes. However, the changes and corresponding The premium changes charges must be submitted to and approved by the Office pursuant to Sections 627.410, 627.411 and 627.674, F.S.
(e) A “noncancellable,” “guaranteed renewable,” or “noncancellable and guaranteed renewable” Medicare supplement policy shall not:
1. 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; or
2. Be cancelled or nonrenewed by the issuer solely on the grounds of deterioration of health.
(f)1. Except as authorized by the Office, a An issuer shall neither cancel nor nonrenew a Medicare supplement policy or certificate for any reason other than nonpayment of premium or material misrepresentation.
2.a. If a group Medicare supplement insurance policy is terminated by the group policyholder and not replaced as provided in subparagraph 69O-156.006(1)(f)4., F.A.C., the issuer shall offer certificateholders an individual Medicare supplement policy. The issuer shall offer the certificateholder at least the following choices:
(I) An individual Medicare supplement policy currently offered by the issuer having comparable benefits to those contained in the terminated group Medicare supplement policy; and
(II) An individual Medicare supplement policy which provides only such benefits as are required to meet the minimum standards as defined in subsection 69O-156.0075(2), 69O-156.008(5)(a) or (b), F.A.C.
b. In either case, if the group policy was issued on an issue age basis, the individual Medicare supplement policy is issued at the original issue age of the terminated certificateholder, and is at the duration of the terminated certificate at the time of conversion.
3. If membership in a group is terminated, the issuer shall:
a. Offer the certificateholder such conversion opportunities as are described in subparagraph 69O-156.006(1)(f)2., F.A.C.; or
b. At the option of the group policyholder, offer the certificateholder continuation of coverage under the group policy.
4.a. If a group Medicare supplement policy is replaced by another group Medicare supplement policy purchased by the same policyholder, the succeeding issuer shall offer coverage to all persons covered under the old group policy on its date of termination. Coverage under the new group policy shall not result in any exclusion for preexisting conditions that would have been covered under the group policy being replaced.
b. If the terminated group policy was issued on an issue age basis and the policy reserves are transferred to the new insurer, the new group certificates shall retain the original issue ages of the insureds and shall commence at the same duration as the terminated certificates.
(g) Termination of a Medicare supplement policy or certificate shall be without prejudice to any continuous loss which 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 will not be considered in determining a continuous loss.
(h) If a Medicare supplement policy eliminates an outpatient drug benefit as a result of requirements imposed by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, the modified policy shall be deemed to satisfy the guaranteed renewal requirements of this subsection.
(2) No change.
Rulemaking Specific Authority 624.308(1), 627.674(2) FS. Law Implemented 624.307(1), 627.410, 627.411, 627.674, 627.6741 FS. History–New 1-1-81, Formerly 4-51.05, Amended 9-4-89, 12-9-90, Formerly 4-51.005, Amended 1-1-92, 3-4-01, 3-31-02, Formerly 4-156.006, Amended 9-15-05,________.
69O-156.007 Benefit Standards for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued or Delivered on or After January 1, 1992, and with an Effective Date for Coverage Prior to June 1, 2010.
The following standards are applicable to all 1990 standardized Medicare supplement benefit plan policies or certificates delivered or issued for delivery in this state on or after January 1, 1992, and with an effective date for coverage prior to 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.
(1) General Standards. The following standards apply to Medicare supplement policies and certificates and are in addition to all other requirements of this regulation.
(a) through (b) No change.
(c) 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, amount and copayment, or coinsurance amounts. percentage factors. Premiums may be modified to correspond with such changes. The premium changes must be submitted to and approved by the Office pursuant to Sections 627.410, and 627.411 and 627.674, F.S.
(d) through (g) No change.
(h) If an issuer makes a written offer to the Medicare Supplement policyholders or certificateholders of one or more of its plans, to exchange during a specified period from his or her 1990 Standardized benefit plan, as described in Rule 69O-156.008, F.A.C., to a 2010 Standardized benefit plan, as described in Rule 69O-156.0085, F.A.C., the offer and subsequent exchange shall comply with the following requirements:
1. An issuer need not provide justification to the Office if the insured replaces a 1990 Standardized benefit plan policy or certificate with an issue age rated 2010 Standardized benefit plan 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 such offer, the rate charged to the insured for the new exchanged policy shall recognize the policy reserve buildup, due to the pre-funding 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 must be submitted to and approved by the Office pursuant to Sections 627.410, 627.411 and 627.674, F.S.
2. The rating class of the new policy or certificate shall be the class closest to the insured’s class of the replaced coverage.
3. An issuer may not apply new preexisting condition limitations or a new incontestability period to the new policy for those benefits contained in the exchanged 1990 Standardized benefit plan policy or certificate of the insured, but may apply preexisting condition limitations of no more than six (6) months to any added benefits contained in the new 2010 Standardized benefit plan policy or certificate not contained in the exchanged policy.
4. The new policy or certificate shall be offered to all policyholders or certificateholders within a given plan, except where the offer or issue would be in violation of state or federal law.
(2) No change.
(3) Standards for Additional Benefits. The following additional benefits shall be included in Medicare Supplement Benefit Plans “B” through “J” only as provided by Rule 69O-156.008, F.A.C.
(a) through (h) No change.
(i)1. Preventive Medical Care Benefit: Coverage for the following preventive health services not covered by Medicare:
i.1. An annual clinical preventive medical history and physical examination that may include tests and services from sub-subparagraph subparagraph 69O-156.007(3)(i)1.ii., 69O-156.007(3)(i)2., F.A.C., and patient education to address preventive health care measures.
ii.2. Preventive screening tests or preventive services, the selection and frequency of which is determined to be medically appropriate by the attending physician.
2.3 Reimbursement shall be for the actual charges up to one hundred percent (100%) 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, to a maximum of one hundred twenty dollars ($120) annually under this benefit. This benefit shall not include payment for any procedure covered by Medicare.
(j) No change.
(4) No change.
Rulemaking Specific Authority 624.308, 627.674(2)(a) FS. Law Implemented 624.307(1), 627.410, 627.674, 627.6741 FS. History– New 1-1-92, Amended 7-26-99, 3-4-01, 3-31-02, Formerly 4-156.007, Amended 9-15-05,________.
69O-156.0075 Benefit Standards for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery with an Effective Date for Coverage on or After June 1, 2010.
The following standards are applicable to all 2010 Standardized Medicare supplement policies or certificates delivered or issued for delivery in this state with an effective date for coverage 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 on or after June 1, 2010. Benefit 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 Rules 69O-156.006, 69O-156.007, and 69O-156.008, F.A.C.
(1) General Standards. The following standards apply to Medicare supplement policies and certificates and are in addition to all other requirements of this rule.
(a) A Medicare supplement policy or certificate shall not exclude or limit benefits for losses incurred more than six (6) months from the effective date of coverage because it involved a preexisting condition. The policy or certificate 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 (6) months before the effective date of coverage.
(b) A Medicare supplement policy or certificate shall not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents.
(c) 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, co-payment, or coinsurance amounts. Premiums may be modified to correspond with such changes. The premium changes must be submitted to and approved by the Office pursuant to Sections 627.410, 627.411, and 627.674, F.S.
(d) No Medicare supplement policy or certificate shall 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.
(e) Each Medicare supplement policy shall be guaranteed renewable.
1. The issuer shall not cancel or nonrenew the policy solely on the ground of health status of the individual.
2. The issuer shall not cancel or nonrenew the policy for any reason other than nonpayment of premium or material misrepresentation.
3.a. If the Medicare supplement policy is terminated by the group policyholder and is not replaced as provided under subparagraph 69O-156.0075(1)(e)5., F.A.C., the issuer shall offer certificateholders an individual Medicare supplement policy which, at the option of the certificateholder:
(I) Provides for continuation of the benefits contained in the group policy; or
(II) Provides for benefits that otherwise meet the requirements of this rule.
b. In either case, if the group policy was issued on an issue age basis, the individual Medicare supplement policy is issued at the original issue age of the terminated certificateholder, and is at the duration of the terminated certificate at the time of conversion.
4. If an individual is a certificateholder in a group Medicare supplement policy and the individual terminates membership in the group, the issuer shall:
a. Offer the certificateholder the conversion opportunity described in subparagraph 69O-156.0075(1)(e)3., F.A.C.; or
b. At the option of the group policyholder, offer the certificateholder continuation of coverage under the group policy.
5.a. 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.
b. If the terminated group policy was issued on an issue age basis and the policy reserves are transferred to the new insurer, the new group certificates shall retain the original issue ages of the insureds and shall commence at the same duration as the terminated certificates.
6. If an individual Medicare supplement policy/certificate is issued to replace an existing issue age rated policy/certificate of the same insurer, the replacing policy/certificate shall be issued at the original issue age of the policyholder/certificateholder, and is at the duration of the terminated policy/certificate at the time of replacement.
(f) Termination of a Medicare supplement policy or certificate shall be without prejudice to any continuous loss which commenced while the policy was in force, but the extension of benefits beyond the period during which the policy was in force may be conditioned 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 will not be considered in determining a continuous loss.
(g)1. 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 certificateholder for the period (not to exceed twenty-four (24) months) in which the policyholder or certificateholder has applied for and is determined to be entitled to medical assistance under Title XIX of the Social Security Act, but only if the policyholder or certificateholder notifies the issuer of the policy or certificate within ninety (90) days after the date the individual becomes entitled to assistance.
2. If suspension occurs and if the policyholder or certificateholder loses entitlement to medical assistance, 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 certificateholder provides notice of loss of entitlement within ninety (90) days after the date of loss and pays the premium attributable to the period, effective as of the date of termination of entitlement.
3. 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 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 if the policyholder or certificateholder 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 ninety (90) days after the date of the loss and pays the premium attributable to the period, effective as of the date of termination of enrollment in the group health plan.
4. Reinstitution of coverages as described in Subparagraphs 2. and 3.:
1. Shall not provide for any waiting period with respect to treatment of preexisting conditions;
2. Shall provide for resumption of coverage that is substantially equivalent to coverage in effect before the date of suspension; and
3. Shall provide for classification of premiums on terms at least as favorable to the policyholder or certificateholder as the premium classification terms that would have applied to the policyholder or certificateholder had the coverage not been suspended.
(2) Standards for Basic (Core) Benefits Common to Medicare Supplement Insurance Benefit Plans A, B, C, D, F, F with 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. 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.
(a) 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;
(b) 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;
(c) Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of one hundred percent (100%) 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;
(d) Coverage under Medicare Parts A and B for the reasonable cost of the first three (3) pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulations) unless replaced in accordance with federal regulations;
(e) Coverage for the coinsurance amount, or in the case of hospital outpatient department services paid under a prospective payment system, the co-payment amount, of Medicare eligible expenses under Part B regardless of hospital confinement, subject to the Medicare Part B deductible;
(f) Hospice Care: Coverage of cost sharing for all Part A Medicare eligible hospice care and respite care expenses.
(3) Standards for Additional Benefits. The following additional benefits shall be included in Medicare supplement benefit Plans B, C, D, F, F with High Deductible, G, M, and N as provided by Rule 69O-156.0085, F.A.C.
(a) Medicare Part A Deductible: Coverage for one hundred percent (100%) of the Medicare Part A inpatient hospital deductible amount per benefit period.
(b) Medicare Part A Deductible: Coverage for fifty percent (50%) of the Medicare Part A inpatient hospital deductible amount per benefit period.
(c) 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.
(d) Medicare Part B Deductible: Coverage for one hundred percent (100%) of the Medicare Part B deductible amount per calendar year regardless of hospital confinement.
(e) One Hundred Percent (100%) 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.
(f) Medically Necessary Emergency Care in a Foreign Country: Coverage to the extent not covered by Medicare for eighty percent (80%) 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 sixty (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.
Rulemaking Authority 624.308, 627.674(2)(a) FS. Law Implemented 624.307(1), 627.410, 627.674, 627.6741 FS. History–New ___________.
69O-156.008 Standard Medicare Supplement Benefit Plans for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or After January 1, 1992, and with an Effective Date for Coverage Prior to June 1, 2010.
The following applies to all 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates issued for delivery on or after January 1, 1992, and with an effective date for coverage prior to June 1, 2010.
(1) through (4) No change.
(5)(a) through (c) No change.
(d) Standardized Medicare supplement benefit plan “D” shall include only the following: The Core Benefit (as defined in subsection paragraphs 69O-156.007(2)(a), (b), (h) and (j), F.A.C., of this rule), plus the Medicare Part A Deductible, Skilled Nursing Facility Care, Medically Necessary Emergency Care in a Foreign Country and the At-Home Recovery Benefit as defined in paragraphs 69O-156.007(2)(a), (b), (h) and (j), F.A.C., respectively.
(e) through (l) No change.
(6) through (7) No change.
Rulemaking Specific Authority 624.308, 627.674(2) FS. Law Implemented 624.307(1), 627.674, 627.6741 FS. History–New 1-1-92, Amended 12-17-96, 7-26-99, Formerly 4-156.008, Amended 9-15-05,_______.
69O-156.0085 Standard Medicare Supplement Benefit Plans for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery with an Effective Date for Coverage on or After June 1, 2010.
The following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this state with an effective date for coverage 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 for coverage before June 1, 2010, remain subject to the requirements of Rules 69O-156.006, 69O-156.007, and 69O-156.008, F.A.C.
(1)(a) An issuer shall make available to each prospective policyholder and certificateholder a policy form or certificate form containing only the basic (core) benefits, as defined in subsection 69O-156.0075(2), F.A.C.
(b) If an issuer makes available any of the additional benefits described in subsection 69O-156.0075(3), F.A.C., or offers standardized benefit Plans K or L as described in paragraphs 69O-156.0085(5)(h) and (i), F.A.C., then the issuer shall make available to each prospective policyholder and certificateholder, in addition to a policy form or certificate form with only the basic (core) benefits as described in paragraph (1)(a) above, a policy form or certificate form containing either standardized benefit Plan C as described in paragraph 69O-156.0085(5)(c), F.A.C., or standardized benefit Plan F as described in paragraph 69O-156.0085(5)(e), F.A.C.
(2) No groups, packages or combinations of Medicare supplement benefits other than those listed in this rule shall be offered for sale in this state, except as may be permitted in subsections 69O-156.0085(6) and 69O-156.030, F.A.C.
(3)(a) Benefit plans shall be uniform in structure, language, designation and format to the standard benefit plans listed in this Subsection and as provided in Form OIR-B2-MSC2 (05/09), “Outline of Coverage, Benefit Plans, Benefit Chart of Medicare Supplement Plans Sold on or After June 1, 2010”, and shall conform to the definitions in Rule 69O-156.003, F.A.C.
(b) Form OIR-B2-MSC2 (05/09), “Outline of Coverage, Benefit Plans, Benefit Chart of Medicare Supplement Plans Sold on or After June 1, 2010”, is hereby adopted and incorporated by reference, and is available and may be printed from the Office’s website: http://www.floir.com, by entering the form number in the search screen.
(c) Each benefit shall be structured in accordance with the format provided in subsections 69O-156.0075(2) and 69O-156.0075(3), F.A.C.; or, in the case of plans K or L, in paragraph 69O-156.0085(5)(h) or 69O-156.0085(5)(i), F.A.C. and list the benefits in the order shown. For purposes of this Section, “structure, language, and format” means style, arrangement and overall content of a benefit.
(4) In addition to the benefit plan designations required in subsection 69O-156.0085(3), F.A.C., an issuer may use other designations to the extent permitted by law.
(5) Make-up of 2010 Standardized Benefit Plans:
(a) Standardized Medicare supplement benefit Plan A shall include only the following: The basic (core) benefits as defined in subsection 69O-156.0075(2), F.A.C.
(b) Standardized Medicare supplement benefit Plan B shall include only the following: The basic (core) benefit as defined in subsection 69O-156.0075(2), F.A.C., plus one hundred percent (100%) of the Medicare Part A deductible as defined in paragraph 69O-156.0075(3)(a), F.A.C.
(c) Standardized Medicare supplement benefit Plan C shall include only the following: The basic (core) benefit as defined in subsection 69O-156.0075(2), F.A.C., plus one hundred percent (100%) of the Medicare Part A deductible, skilled nursing facility care, one hundred percent (100%) of the Medicare Part B deductible, and medically necessary emergency care in a foreign country as defined in paragraphs 69O-156.0075(3)(a), (c), (d), and (f), F.A.C., respectively.
(d) Standardized Medicare supplement benefit Plan D shall include only the following: The basic (core) benefit, as defined in subsection 69O-156.0075(2), F.A.C., plus one hundred percent (100%) of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in an foreign country as defined in paragraphs 69O-156.0075(3)(a), (c), and (f), F.A.C., respectively.
(e) Standardized Medicare supplement [regular] Plan F shall include only the following: The basic (core) benefit as defined in subsection 69O-156.0075(2), F.A.C., plus one hundred percent (100%) of the Medicare Part A deductible, the skilled nursing facility care, one hundred percent (100%) of the Medicare Part B deductible, one hundred percent (100%) of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in paragraphs 69O-156.0075(3)(a), (c), (d), (e), and (f), F.A.C., respectively.
(f) Standardized Medicare supplement Plan F With High Deductible shall include only the following: one hundred percent (100%) of covered expenses following the payment of the annual deductible set forth in Subparagraph 2. below.
1. The basic (core) benefit as defined in subsection 69O-156.0075(2), F.A.C., plus one hundred percent (100%) of the Medicare Part A deductible, skilled nursing facility care, one hundred percent (100%) of the Medicare Part B deductible, one hundred percent (100%) of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in paragraphs 69O-156.0075(3)(a), (c), (d), (e), and (f), F.A.C., respectively.
2. The annual deductible in Plan F With High Deductible shall consist of out-of-pocket expenses, other than premiums, for services covered by [regular] 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 of the U.S. Department of Health and Human Services to reflect the change in the Consumer Price Index for all urban consumers for the twelve-month period ending with August of the preceding year, and rounded to the nearest multiple of ten dollars ($10).
(g) Standardized Medicare supplement benefit Plan G shall include only the following: The basic (core) benefit as defined in subsection 69O-156.0075(2), F.A.C., plus one hundred percent (100%) of the Medicare Part A deductible, skilled nursing facility care, one hundred percent (100%) of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in paragraphs 69O-156.0075(3)(a), (c), (e), and (f), F.A.C., respectively.
(h) Standardized Medicare supplement Plan K is mandated by The Medicare Prescription Drug, Improvement and Modernization Act of 2003, and shall include only the following:
1. Part A Hospital Coinsurance 61st through 90th days: Coverage of one hundred percent (100%) of the Part A hospital coinsurance amount for each day used from the 61st through the 90th day in any Medicare benefit period;
2. Part A Hospital Coinsurance, 91st through 150th days: Coverage of one hundred percent (100%) 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;
3. Part A Hospitalization After 150 Days: Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of one hundred percent (100%) 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. Medicare Part A Deductible: Coverage for fifty percent (50%) of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in Subparagraph 10.;
5. Skilled Nursing Facility Care: Coverage for fifty percent (50%) 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 10.;
6. Hospice Care: Coverage for fifty percent (50%) 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 10.;
7. Blood: Coverage for fifty percent (50%), under Medicare Part A or B, of the reasonable cost of the first three (3) 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 10.;
8. Part B Cost Sharing: Except for coverage provided in Subparagraph (i), coverage for fifty percent (50%) 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 10.;
9. Part B Preventive Services: Coverage of one hundred percent (100%) of the cost sharing for Medicare Part B preventive services after the policyholder pays the Part B deductible; and
10. Cost Sharing After Out-of-Pocket Limits: Coverage of one hundred percent (100%) 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 $4000 in 2006, indexed each year by the appropriate inflation adjustment specified by the Secretary of the U.S. Department of Health and Human Services.
(i) Standardized Medicare supplement Plan L is mandated by The Medicare Prescription Drug, Improvement and Modernization Act of 2003, and shall include only the following:
1. The benefits described in subparagraphs 69O-156.0085(5)(h)1., 2., 3., and 9., F.A.C.;
2. The benefit described in subparagraphs 69O-156.0085(5)(h)4., 5., 6., 7., and 8., F.A.C., but substituting seventy-five percent (75%) for fifty percent (50%); and
3. The benefit described in subparagraph 69O-156.0085(5)(h)10., F.A.C., but substituting $2000 for $4000.
(j) Standardized Medicare supplement Plan M shall include only the following: The basic (core) benefit as defined in subsection 69O-156.0075(2), F.A.C., plus fifty percent (50%) of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in paragraphs 69O-156.0075(3)(b), (c), and (f), F.A.C., respectively.
(k) Standardized Medicare supplement Plan N shall include only the following: The basic (core) benefit as defined in subsection 69O-156.0075(2), F.A.C., plus one hundred percent (100%) of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in paragraphs 69O-156.0075(3)(a), (c) and (f), F.A.C., respectively, with co-payments in the following amounts:
1. The lesser of twenty dollars ($20) or the Medicare Part B coinsurance or co-payment for each covered health care provider office visit (including visits to medical specialists); and
2. The lesser of fifty dollars ($50) or the Medicare Part B coinsurance or co-payment for each covered emergency room visit, however, this co-payment shall be waived if the insured is admitted to any hospital and the emergency visit is subsequently covered as a Medicare Part A expense.
(6) New or Innovative Benefits: An issuer may, with the prior approval of the Office, 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.
Rulemaking Authority 624.308, 627.674(2) FS. Law Implemented 624.307(1), 627.674, 627.6741 FS. History–New_______.
69O-156.0095 Guaranteed Issue for Eligible Persons.
(1) No change.
(2) Eligible Persons. An eligible person is an individual described in any of the following paragraphs:
(a) The individual is enrolled under an employee welfare benefit plan that provides health benefits that supplement the benefits under Medicare, which plan terminates or ceases to provide at least the minimum benefits as provided under a Medicare supplement plan “A” as defined in subsection 69O-156.0085(1), F.A.C., of the supplemental health benefits to the individual;
(b) through (g) No change.
(3) through (6) No change.
Rulemaking Specific Authority 624.308, 627.674(2), 627.6741(5) FS. Law Implemented 624.307(1), 627.410, 627.673, 627.674, 627.6745, 627.6746 FS. History–New 7-26-99, Amended 3-4-01, 3-31-02, Formerly 4-156.0095, Amended 9-15-05,_______.
69O-156.011 Loss Ratio Standards and Refund or Credit of Premium.
(1) Loss Ratio Standards.
(a) through (d) No change.
(e) For the purposes of this rule, the term “pre-standardized business” shall include:
1. All Medicare Supplement policies and certificates which do not comply with the benefit requirements for standardized policies as defined in Rule 69O-156.008 or 69O-156.0085, F.A.C., and
2. All policies and certificates which were marketed and issued as Medicare Supplement policies, and which have been redefined as limited benefit policies.
(f) No change.
(2) Refund or Credit Calculation.
(a)1. No change.
2. Forms OIR-B2-MSB-I (Rev. 06/09 7/02), OIR-B2-MSB-G (Rev. 06/09 7/02), and OIR-B2-MSR (Rev. 7/02) are hereby adopted and incorporated by reference. Copies of forms are available and may be printed from the Office’s website: http://www.floirdfs.com/, by entering the form number in the search screen.
3. Filings shall be submitted electronically to https://iportal.fldfs.com.
(b) through (c) No change.
(3) Annual Filing of Premium Rates.
(a)1. An issuer of Medicare supplement policies and certificates issued before or after January 1, 1992, shall file annually its rates, rating schedule and supporting documentation including ratios of incurred losses to earned premiums by policy duration for approval by the Department in accordance with Sections 627.410, 627.411, and 627.6745, F.S.
2. The supporting documentation shall also demonstrate in accordance with actuarial standards of practice using reasonable assumptions that the appropriate loss ratio standards can be expected to be met over the entire period for which rates are computed. The demonstration shall exclude the change in active life reserves as a component of incurred claims or earned premiums. A projected third-year loss ratio which is greater than or equal to the applicable percentage shall be demonstrated for policies or certificates in force less than three (3) years.
(b) thorugh (c) No change.
(4) No change.
Rulemaking Specific Authority 624.308, 627.674(2) FS. Law Implemented 624.307(1), 627.410, 627.673, 627.674, 627.6745, 627.6746 FS. History–New 1-1-92, Amended 7-14-96, 12-17-96, 7-26-99, 3-4-01, 12-9-02, 6-19-03, Formerly 4-156.011, Amended 9-15-05,_______.
69O-156.012 Filing and Approval of Policies and Certificates and Premium Rates.
(1) through (2) No change.
(3)(a) through (c) No change.
(d) Acceptable rate classification criteria within a form include only age, gender, area and smoker status or tobacco usage.
(4) No change.
(5)(a) Except as provided in paragraph 69O-156.012(5)(b), F.A.C., the experience of all policy forms or certificate forms of the same type in a standard Medicare supplement benefit plan shall be combined for purposes of the refund or credit calculation prescribed in Rule 69O-156.011, F.A.C., and for all other rating purposes. The issue date of a standard Medicare supplement benefit plan is not a basis to separate experience of two or more plans of the same plan letter.
(b) Forms assumed under an assumption reinsurance agreement shall not be combined with the experience of other forms for purposes of the refund or credit calculation.
Rulemaking Specific Authority 624.308 FS. Law Implemented 624.307(1), 627.410, 627.411, 627.674 FS. History–New 1-1-92, Amended 7-14-96, 3-4-01, Formerly 4-156.012, Amended 9-15-05,_______.
69O-156.020 Prohibition Against Use of Genetic Information and Requests for Genetic Testing.
This rule applies to all policies and certificates with policy years beginning on or after May 21, 2009.
(1) An issuer of a Medicare supplement policy or certificate;
(a) Shall not deny or condition the issuance or effectiveness of the policy or certificate (including the imposition of any exclusion of benefits under the policy based on a preexisting condition) on the basis of the genetic information with respect to such individual; and
(b) Shall not discriminate in the pricing of the policy or certificate (including the adjustment of premium rates) of an individual on the basis of the genetic information with respect to such individual.
(2) Nothing in subsection 69O-156.020(1), F.A.C., shall be construed to limit the ability of an issuer, to the extent otherwise permitted by law, from:
(a) Denying or conditioning the issuance or effectiveness of the policy or certificate or increasing the premium for a group based on the manifestation of a disease or disorder of an insured or applicant; or
(b) Increasing the premium for any policy issued to an individual based on the manifestation of a disease or disorder of an individual who is covered under the policy (in such case, the manifestation of a disease or disorder in one individual cannot also be used as genetic information about other group members and to further increase the premium for the group).
(3) An issuer of a Medicare supplement policy or certificate shall not request or require an individual or a family member of such individual to undergo a genetic test.
(4) Subsection 69O-156.020(3), F.A.C., shall not be construed to preclude an issuer of a Medicare supplement policy or certificate from obtaining and using the results of a genetic test in making a determination regarding payment (as defined for the purposes of applying the regulations promulgated under part C of title XI and section 264 of the Health Insurance Portability and Accountability Act of 1996, as may be revised from time to time) and consistent with subsection 69O-156.020(1), F.A.C.
(5) For purposes of carrying out subsection 69O-156.020(4), F.A.C., an issuer of a Medicare supplement policy or certificate may request only the minimum amount of information necessary to accomplish the intended purpose.
(6) Notwithstanding subsection 69O-156.020(3), F.A.C., an issuer of a Medicare supplement policy may request, but not require, that an individual or a family member of such individual undergo a genetic test if each of the following conditions is met:
(a) The request is made pursuant to research that complies with part 46 of title 45, Code of Federal Regulations, or equivalent Federal regulations, and any applicable State or local law or regulations for the protection of human subjects in research.
(b) The issuer clearly indicates to each individual, or in the case of a minor child, to the legal guardian of such child, to whom the request is made that:
1. Compliance with the request is voluntary; and
2. Non-compliance will have no effect on enrollment status or premium or contribution amounts.
(c) No genetic information collected or acquired under this Subsection shall be used for underwriting, determination of eligibility to enroll or maintain enrollment status, premium rates, or the issuance, renewal, or replacement of a policy or certificate.
(d) The issuer notifies the Secretary in writing that the issuer is conducting activities pursuant to the exception provided for under this Subsection, including a description of the activities conducted.
(e) The issuer complies with such other conditions as the Secretary may by regulation require for activities conducted under this Subsection.
(7) An issuer of a Medicare supplement policy or certificate shall not request, require, or purchase genetic information for underwriting purposes.
(8) An issuer of a Medicare supplement policy or certificate shall not request, require, or purchase genetic information with respect to any individual prior to such individual’s enrollment under the policy in connection with such enrollment.
(9) If an issuer of a Medicare supplement policy or certificate obtains genetic information incidental to the requesting, requiring, or purchasing of other information concerning any individual, such request, requirement, or purchase shall not be considered a violation of subsection 69O-156.020(8), F.A.C., if such request, requirement, or purchase is not in violation of subsection 69O-156.020(7), F.A.C.
(10) For the purposes of this Section only:
(a) “Issuer of a Medicare supplement policy or certificate” includes third-party administrator, or other person acting for or on behalf of such issuer.
(b) “Family member” means, with respect to an individual, any other individual who is a first-degree, second-degree, third-degree, or fourth-degree relative of such individual.
(c) “Genetic information” means, with respect to any individual, information about such individual’s genetic tests, the genetic tests of family members of such individual, and the manifestation of a disease or disorder in family members of such individual. Such term includes, with respect to any individual, any request for, or receipt of, genetic services, or participation in clinical research which includes genetic services, by such individual or any family member of such individual. Any reference to genetic information concerning an individual or family member of an individual who is a pregnant woman, includes genetic information of any fetus carried by such pregnant woman, or with respect to an individual or family member utilizing reproductive technology, includes genetic information of any embryo legally held by an individual or family member. The term “genetic information” does not include information about the sex or age of any individual.
(d) “Genetic services” means a genetic test, genetic counseling (including obtaining, interpreting, or assessing genetic information), or genetic education.
(e) “Genetic test” means an analysis of human DNA, RNA, chromosomes, proteins, or metabolites, that detect genotypes, mutations, or chromosomal changes. The term “genetic test” does not mean an analysis of proteins or metabolites that does not detect genotypes, mutations, or chromosomal changes; or an analysis of proteins or metabolites that is directly related to a manifested disease, disorder, or pathological condition that could reasonably be detected by a health care professional with appropriate training and expertise in the field of medicine involved.
(f) “Underwriting purposes” means:
1. Rules for, or determination of, eligibility (including enrollment and continued eligibility) for benefits under the policy;
2. The computation of premium or contribution amounts under the policy;
3. The application of any preexisting condition exclusion under the policy; and
4. Other activities related to the creation, renewal, or replacement of a contract of health insurance or health benefits.
Rulemaking Authority 627.674 FS. Law Implemented 627.6741 FS. History–New________. |
