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D.C. Municipal Regulations (Last Updated: September 13, 2017) |
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Title 26. INSURANCE, SECURITIES, AND BANKING |
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SubTilte 26-A. INSURANCE |
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Chapter 26-A22. MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS |
Section 26-A2208. STANDARD MEDICARE SUPPLEMENT BENEFIT PLANS
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2208.1An issuer shall make available to each prospective policyholder and certificate holder a policy form or certificate form containing only the Basic "Core" Benefits, as defined in subsection 2207.14.
2208.2No groups, packages or combinations of Medicare supplement benefits other than those listed in this section shall be offered for sale in the District, except as may be permitted in subsection 2208.9 and 2208A.
2208.3Benefit plans shall be uniform in structure, language, designation and format to the Standard Benefit Plans "A" through "L" listed in this subsection and conform to the definitions in section 2299.
2208.4Each benefit shall be structured in accordance with the format provided in subsections 2207.14 and 2207.15 or 2207.16 and list the benefits in the order shown in subsection 2208.7.
2208.5For purposes of section 2208, "structure, language, and format" means style, arrangement and overall content of a benefit.
2208.6An issuer may use, in addition to the benefit plan designations required in subsection 2208.3, other designations to the extent permitted under District law.
2208.7Make-up of benefit plans:
(a)Standardized Medicare supplement benefit plan "A" shall be limited to the Basic ("Core") Benefits common to all benefit plans, as defined in subsection 2207.14;
(b)Standardized Medicare supplement benefit plan "B" shall include only the following:
(1)The Core Benefit as defined in subsection 2207.14; plus
(2)The Medicare Part A Deductible as defined in subsection 2207.15(a);
(c)Standardized Medicare supplement benefit plan "C" shall include only the following:
(1)The Core Benefit as defined in subsection 2207.14; and
(2)The Medicare Part A Deductible, Skilled Nursing Facility Care, Medicare Part B Deductible and Medically Necessary Emergency Care in a foreign Country as defined in subsection 2207.15(a), (b), (c), and (h);
(d)Standardized Medicare supplement benefit plan "D" shall include only the following:
(1)The Core Benefit as defined in subsection 2207.14; and
(2)The Medicare Part A Deductible, Skilled Nursing Facility Care, Medically Necessary Emergency Care in an foreign Country and the At-Home Recovery Benefit as defined in subsections 2207.15(a) and (b), (h), and (j);
(e)Standardized Medicare supplement benefit plan "E" shall include only the following:
(1)The Core Benefit as defined in subsection 2207.14; and
(2)The Medicare Part A Deductible, Skilled Nursing Facility Care, Medically Necessary Emergency Care in a foreign Country and Preventive Medical Care as defined in subsection 2207.5(a), (b), (h), and (i);
(f)
(1)Standardized Medicare supplement benefit plan "F" shall include only the following:
(A)The Core Benefit as defined in subsection 2207.14; and
(B)The Medicare Part A Deductible, the Skilled Nursing Facility Care, the 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 subsections 2207.15(a), (b), (c), (e), and (h);
(2)Standardized Medicare supplement benefit high deductible "F" shall include only the following: one hundred percent (100%) of covered expenses following the payment of the annual high deductible plan "F" deductible. The covered expenses include the core benefit as defined in section 2207.14, plus the Medicare Part A deductible, skilled nursing facility care, 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 section 2207.15(a), (b), (c), (e), and (h). The annual high deductible plan "F" deductible shall consist of out-of-pocket expenses, other than premiums, for services covered by the Medicare supplement plan "F" policy, and shall be in addition to any other specific benefit deductibles. The annual high deductible plan "F" deductible shall be $ 1500 for 1998 and 1999 and shall be based on the calendar year. It shall be adjusted annually thereafter by the Secretary to reflect the change in the Consumer Price Index for all urban consumers for the twelve (12)-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:
(1)The Core Benefit as defined in subsection 2207.14; and
(2)The Medicare Part A Deductible, the Skilled Nursing Facility Care, Eighty Percent (80%) of the Medicare Part B Excess Charges, Medically Necessary Emergency Care in a Foreign Country, and the At-Home Recovery Benefit as defined in subsections 2207.15(a), (b), (d), (h), and (j);
(h)Standardized Medicare supplement benefit plan "H" shall consist of only the following:
(1)The Core Benefit as defined in subsection 2207.14;
(2)The Medicare Part A Deductible, Skilled Nursing Facility Care, Basic Prescription Drug Benefit and Medically Necessary Emergency Care in a Foreign Country as defined in subsections 2207.15(a), (b), (f), and (h); and
(3)The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005.
(i)Standardized Medicare supplement benefit plan "I" shall consist of only the following:
(1)The Core Benefit as defined in subsection 2207.14;
(2)The Medicare Part A Deductible, Skilled Nursing Facility Care, One Hundred Percent (100%) of the Medicare Part B Excess Charges, Basic Prescription Drug Benefit, Medically Necessary Emergency Care in a Foreign Country and At-Home Recovery Benefit as defined in subsections 2207.15(a), (b), (e), (f), (h), and (j); and
(3)The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005;
(j)Standardized Medicare supplement benefit plan "J" shall consist of only the following:
(1)The Core Benefit as defined in subsection 2207.14; and
(2)The Medicare Part A Deductible, Skilled Nursing Facility Care, Medicare Part B Deductible, One Hundred Percent (100%) of the Medicare Part B Excess Charges, Extended Prescription Drug Benefit, Medically Necessary Emergency Care in a foreign Country, Preventive Medical Care and At-Home Recovery Benefit as defined in subsections 2207.15(a), (b), (c), (e), (g), (h), (i), and (j); and
(3)The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005; and
(k)Deleted;
(l)Standardized Medicare supplement benefit high deductible plan "J" shall consist of only the following: 100% of covered expenses following the payment of the annual high deductible plan "J" deductible. The covered expenses include the core benefit as defined in section 2207 of this regulation, plus the Medicare Part A deductible, skilled nursing facility care, Medicare Part B deductible, one hundred percent (100%) of the Medicare Part B excess charges, extended outpatient prescription drug benefit, medically necessary emergency care in a foreign country, preventive medical care benefit and at-home recovery benefit as defined in sections 2207.15(a), (b), (c), (d), (h), (i) and (j) respectively. The annual high deductible plan "J" deductible shall consist of out-of-pocket expenses other than premiums for services covered by the Medicare supplement "J" policy, and shall be in addition to any other specific benefit deductibles. The annual deductible shall be fifteen hundred dollars ($1500) for 1998 and 1999, and shall be based on the calendar year. It shall include the annual adjustments made thereafter by the Secretary 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). The outpatient prescription drug benefit shall not be included in a Medicare supplement policy sold after December 31, 2005.
2208.8Make-up of two Medicare supplement plans mandated by the Medicare Prescription Drug, Improvement and Modernization Act of 2003:
(a)Standardized Medicare supplement benefit plan "K" shall consist of only those benefits described in subsection 2207.16(a).
(b)Standardized Medicare supplement benefit plan "L" shall consist of only those benefits described in subsection 2207.16(b).
2208.9New or Innovative Benefits: An issuer may, with the prior approval of the Commissioner, offer policies or certificates with new or innovative benefits in addition to the benefits provided in a policy or certificate that otherwise complies with the applicable standards. The new or innovative benefits may include benefits that are appropriate to Medicare supplement insurance, new or innovative, not otherwise available, cost-effective, and offered in a manner which is consistent with the goal of simplification of Medicare supplement policies. After December 31, 2005, the innovative benefit shall not include an outpatient prescription drug benefit.
SOURCE: Final Rulemaking published at 46 DCR 10175 (December 17, 1999); as amended by Final Rulemaking published at 50 DCR 4166 (May 30, 2003); as amended by Final Rulemaking published at 50 DCR 5882 (July 25, 2003); as amended by Final Rulemaking published at 53 DCR 2955(April 14, 2006); as amended by Final Rulemaking published at 53 DCR 8467(October 20, 2006).
2208aSTANDARD MEDICARE SUPPLEMENT BENEFIT PLANS FOR 2010 STANDARDIZED MEDICARE SUPPLEMENT BENEFIT PLAN POLICIES OR CERTIFICATES ISSUED FOR DELIVERY ON OR AFTER JUNE 1, 2010
2208a-1The following standards in subsection 2208a-2 through 2208a-8 are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in the District on or after June 1, 2010.
2208a-2No policy or certificate may be advertised, solicited, delivered or issued for delivery in the District as a Medicare supplement policy or certificate unless it complies with the benefits standards in this section.
2208a-3Benefit plan standards applicable to Medicare supplement policies and certificates issued before June 1, 2010, remain subject to the requirements of section 2208 of this chapter.
2208a-4An issuer shall make available to each prospective policyholder and certificate holder a policy form or certificate form containing only the basic (core) Benefits, as defined in subsection 2207a-24 of this chapter.
2208a-5If an issuer makes any of the additional benefits described in subsection 2207a-25 or offers standardized benefit Plans K or L (as described in subparagraphs 2208a-9(h) and (i)), then the issuer shall make available to each prospective policyholder and certificate holder, in addition to a policy form or certificate form with only the basic (core) benefits as described in subsection 2208a-4 above, a policy form or certificate form containing either standardized benefit Plan C (as described in subparagraph 2008a-9(c) of this chapter) or standard benefit Plan F (as described in subparagraph 2008a-9(e).
2208a-6 No groups, packages, or combinations of Medicare supplement benefits other than those listed in this section shall be offered for sale in the District, except as may be permitted in subsection 2208a-10.
2208a-7Benefit plans shall be uniform in structure, language, designation, and format to the standard benefit plans listed in this subsection and conform to the definition in section 2299 of this chapter. Each benefit shall be structured in accordance with the format provided in subsections 2207a-24 and 2207a-25; or, in the case of plans K or L, in subparagraphs 2208a-9(h) or (i) and list the benefits in the order shown. For purposes of this subsection, “structure, language, and format” means style, arrangement and overall content of a benefit.
2208a-8In addition to the benefit plan designations required in subsection 2208a-7, an issuer may use other designations to the extent permitted by law.
2208a-9The composition of 2010 Standard Benefit Plans shall be as follows:
(a) Standardized Medicare supplement benefit plan A shall include only the basic (core) benefits as defined in subsection 2207a-24.
(b) Standardized Medicare supplement benefit plan B shall include only the following:
(1)The basic (core) benefit as defined in subsection 2207a-24 of this chapter; and
(2)One hundred percent (100%) of the Medicare Part A deductible as defined in subparagraph 2207a-25(a) of this chapter.
(c)Standardized Medicare supplement benefit plan C shall include only the following:
(1)The basic (core) benefit as defined in subsection 2207a-24 of this chapter; plus
(2)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 subparagraphs 2207a-25 (a), (c), (d), and (f), of this chapter, respectively.
(d)Standardized Medicare supplement benefit plan D shall include the following:
(1) The basic (core) benefit (as defined in the subsection 2207a-24 of this chapter); and
(2)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 subparagraphs 2207a-25 (a), (c), and (f) of this chapter.
(e)Standardized Medicare supplement plan F shall include only the following:
(1)The basic (core) benefit as defined in subsection 2207a-24 of this chapter; and
(2)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 subparagraphs 2207a-25(a), (c), (d), (e), and (f) of this chapter.
(f)Standardized Medicare supplement plan F with High Deductible shall include only the following:
(1)One hundred percent (100%) of covered expenses following the payment of the annual deductible set forth in subparagraph (3);
(2)The basic (core) benefit as defined in subsection 2207a-24 and:
(A)One hundred percent (100%) of the Medicare Part A deductible, Skilled Nursing Facility Care;
(B)One hundred percent (100%) of the Medicare part “B” deductible;
(C) One hundred percent (100%) of the Medicare Part “B” excess charges; and
(D) Medically necessary emergency care in a foreign country as defined in subparagraphs 2207a-25(a), (c), (d), (e) and (f) of this chapter, respectively.
(3)The annual deductible in plan F with High Deductible shall consist of out-of-pocket expense, other than premiums, for services covered by [regular] plan F and shall be in addition to 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:
(1)The basic (core) benefit as described in 2207a-24 of this chapter; and
(2)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 subparagraphs 2207a-25(a),(c), (e), and (f), respectively.
(h)Standardized Medicare supplement plan “K” is mandated by the Medicare Prescription Drug Improvement and Modernization Act of 2003, and shall have the following:
(1)Part A Hospital Coinsurance 61st through 90th days: Coverage of one hundred percent (100%) of the Part A 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 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 9, 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 of 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 2208a-h(1), (2), (3), and (9);
(2) The benefit described in subparagraphs 2208a-h(4), (5), (6), (7), and (8), but substituting seventy-five percent (75%) for fifty percent (50%); and
(3) The benefit described in subparagraph 2208a-h(10), but substituting $2000 for $4000.
(j) Standardized Medicare supplement plan M shall include only the following:
(1)The basic (core) benefit as defined ins subsection 2207a-14; and
(2)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 subparagraphs 2207a-25(b), (c), and (f), respectively.
(k)Standardized Medicare supplement plan N shall include only the following:
(1)The basic (core) benefit as defined in subsection 2207a-14 of this chapter; and
(2)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 subparagraphs 2207a-15(a), (c), and (f) of this chapter, respectively, with co-payments in the following amounts:
(A) 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
(B) 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.
2208a-10New or Innovative Benefits: An issuer may, with the prior approval of the Commissioner, 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 subject to the following conditions:
(a) 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.
(b) Approval of new or innovative benefits must not adversely impact the goal of Medicare supplement simplification;
(c) New or innovative benefits shall not include an outpatient prescription drug benefit; and
(d) New or innovative benefits shall not be used to change or reduce benefits,
including change of any cost-sharing provision, in any standardized plan.