NAC687B.322. Standards for policies to supplement Medicare or certificates effective on or after June 1, 2010.

     1. In addition to the standards set forth in NAC 687B.323, the standards provided for in this section are:

     (a) Applicable to all policies to supplement Medicare or certificates delivered or issued for delivery in this State with an effective date for coverage on or after June 1, 2010; and

     (b) Not applicable to policies to supplement Medicare or certificates delivered or issued for delivery in this State with an effective date for coverage before June 1, 2010.

     2. On or after June 1, 2010, the following standards apply to policies to supplement Medicare and certificates and are in addition to all other requirements:

     (a) A policy to supplement Medicare or a certificate must not:

          (1) Exclude or limit benefits for losses incurred more than 6 months after the effective date of coverage because of a preexisting condition.

          (2) Define a preexisting condition more restrictively than as a condition for which medical advice was given or treatment was recommended by or received from a physician within 6 months before the effective date of coverage.

          (3) Indemnify against any loss resulting from sickness on a different basis than for a loss resulting from an accident.

     (b) A policy to supplement Medicare or a certificate must 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, copayment or coinsurance amounts. Premiums may be modified to correspond with such changes.

     (c) No policy to supplement Medicare or certificate may provide for the 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 premiums.

     (d) A policy to supplement Medicare must be guaranteed renewable and:

          (1) The issuer shall not cancel or fail to renew the policy solely because of the health status of the person.

          (2) The issuer shall not cancel or fail to renew the policy for any other reason than the nonpayment of premiums or for a material misrepresentation.

     (e) If a policy to supplement Medicare is terminated by the group policyholder and is not replaced as provided under paragraph (g), the issuer shall offer to each certificate holder an individual policy to supplement Medicare which, at the option of the certificate holder:

          (1) Provides for the continuation of the benefits contained in the group policy; or

          (2) Provides benefits that otherwise meet the requirements of this subsection.

     (f) If a person is a certificate holder in a group policy to supplement Medicare and the person terminates membership in the group, the issuer shall:

          (1) Offer the certificate holder the conversion opportunity described in paragraph (e); or

          (2) At the option of the group policyholder, offer the certificate holder continuation of coverage under the group policy.

     (g) If a group policy to supplement Medicare is replaced by another group policy to supplement Medicare which is purchased by the same policyholder, the issuer of the replacement policy shall offer coverage to all persons covered under the previous group policy on its date of termination. Coverage under the new policy must not result in the exclusion of coverage for preexisting conditions that would have been covered under the group policy being replaced.

     (h) Termination of a policy to supplement Medicare or a certificate must be without prejudice to any continuous loss that 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, and limited to the duration of the policy benefit period, if any, or to the payment of the maximum benefits. The receipt of Medicare Part D benefits will not be considered in determining a continuous loss.

     (i) A policy to supplement Medicare or a certificate must provide that benefits and premiums under the policy or certificate must be suspended at the request of the policyholder or certificate holder for the period, not to exceed 24 months, during which the policyholder or certificate holder has applied for and is determined to be eligible for medical assistance under Title XIX of the Social Security Act, 42 U.S.C. §§ 1396 et seq., if the policyholder or certificate holder notifies the issuer of the policy or certificate within 90 days after the date the person becomes eligible for such assistance. If benefits or premiums are suspended and the policyholder or certificate holder loses eligibility for such medical assistance, the policy or certificate must be automatically reinstated effective as of the date eligibility is terminated if the policyholder or certificate holder provides notice of loss of eligibility to the insurer within 90 days after the date of loss and pays the premium attributable to the period of eligibility.

     (j) A policy to supplement Medicare or a certificate must provide that benefits and premiums under the policy must be suspended at the request of the policyholder for any period that may be provided by federal regulation if the policyholder is entitled to benefits under section 226(b) of the Social Security Act, 42 U.S.C. § 426(b), and is covered under a group health plan as defined in section 1862(b)(1)(A)(v) of the Social Security Act, 42 U.S.C. § 1395y(b)(1)(A)(v). If benefits and premiums are suspended and the policyholder or certificate holder loses coverage under the group health plan, the policy must be automatically reinstated, effective as of the date of loss of coverage if the policyholder provides notice of loss of coverage within 90 days after the date of the loss and pays the premium attributable to the period.

     (k) Reinstatement of coverage as described in paragraphs (i) and (j):

          (1) Must not provide for any waiting period with respect to treatment of preexisting conditions;

          (2) Must provide for resumption of coverage that is substantially equivalent to the coverage in effect before the premiums and benefits were suspended; and

          (3) Must provide for the classification of premiums on terms at least as favorable to the policyholder or certificate holder as the terms in effect before the benefits and premiums were suspended.

     3. On or after June 1, 2010, every issuer shall make available a policy or certificate which includes a basic core package of benefits to each prospective insured, but an issuer may make available to prospective insureds any of the other benefit plans to supplement Medicare in addition to, but not in lieu of, the basic core package. The basic core package of benefits must consist of:

     (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 100 percent 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, and 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 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 copayment amount, of Medicare eligible expenses under Part B regardless of hospital confinement, subject to the Medicare Part B deductible.

     (f) Coverage of cost sharing for all Part A Medicare eligible hospice care and respite care expenses.

     4. On or after June 1, 2010, the following additional benefits must be included in Standardized Benefit Plans B, C, D, F, F with High Deductible, G, M and N to supplement Medicare as provided by NAC 687B.323:

     (a) Coverage for 100 percent of the Medicare Part A inpatient hospital deductible amount per benefit period;

     (b) Coverage for 50 percent of the Medicare Part A inpatient hospital deductible amount per benefit period;

     (c) 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 posthospital skilled nursing facility care eligible under Medicare Part A;

     (d) Coverage for 100 percent of the Medicare Part B deductible amount per calendar year regardless of hospital confinement;

     (e) 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 Part B charge approved by Medicare; and

     (f) 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 paragraph, “emergency care” means care needed immediately because of an injury or an illness of sudden and unexpected onset.

     (Added to NAC by Comm’r of Insurance by R049-09, eff. 10-27-2009)