NAC687B.323. Requirements regarding policies to supplement Medicare or certificates effective on or after June 1, 2010.

     1. In addition to the standards set forth in NAC 687B.322, 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, an issuer shall make available to each prospective policyholder or certificate holder a policy form or certificate form containing only the basic core benefits, as set forth in subsection 3 of NAC 687B.322.

     3. On or after June 1, 2010, if an issuer makes available any of the additional benefits set forth in subsection 4 of NAC 687B.322, or offers Standardized Benefit Plan K or L as described in paragraphs (h) and (i) of subsection 7, 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 2, a policy form or certificate form containing either Standardized Benefit Plan C as described in paragraph (c) of subsection 7 or Standardized Benefit Plan F as described in paragraph (e) of subsection 7.

     4. On or after June 1, 2010, no group, package or combinations of benefits to supplement Medicare other than those listed in this section may be offered for sale in this State, except as may be permitted in subsection 8 and in NAC 687B.340 to 687B.376, inclusive.

     5. On or after June 1, 2010, a benefit plan must be uniform in structure, language, designation and format to the standardized benefit plans listed in this section and must conform to the definition in NAC 687B.2003. Each benefit must be structured in accordance with the format provided in subsections 3 and 4 of NAC 687B.322 or, in the case of Standardized Benefit Plan K or L, in paragraphs (h) and (i) of subsection 7, and list the benefits in the order shown in the applicable requirements.

     6. On or after June 1, 2010, and in addition to the benefit plans required in subsection 5, an issuer may use other designations to the extent permitted by law.

     7. On or after June 1, 2010, the contents of standardized benefit plans must be as follows:

     (a) A 2010 standardized benefit plan to supplement Medicare which is designated as Standardized Benefit Plan A must include only the basic core benefits as defined in subsection 3 of NAC 687B.322.

     (b) A 2010 standardized benefit plan to supplement Medicare which is designated as Standardized Benefit Plan B must include only the basic core benefits as defined in subsection 3 of NAC 687B.322, plus 100 percent of the Medicare Part A deductible as defined in paragraph (a) of subsection 4 of NAC 687B.322.

     (c) A 2010 standardized benefit plan to supplement Medicare which is designated as Standardized Benefit Plan C must include only the basic core benefits as defined in subsection 3 of NAC 687B.322, 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 defined in paragraphs (a), (c), (d) and (f) of subsection 4 of NAC 687B.322, respectively.

     (d) A 2010 standardized benefit plan to supplement Medicare which is designated as Standardized Benefit Plan D must include only the basic core benefits as defined in subsection 3 of NAC 687B.322, plus 100 percent of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in paragraphs (a), (c) and (f) of subsection 4 of NAC 687B.322, respectively.

     (e) A 2010 standardized benefit plan to supplement Medicare which is designated as Standardized Benefit Plan F must include only the basic core benefits as defined in subsection 3 of NAC 687B.322, 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 defined in paragraphs (a), (c), (d), (e) and (f) of subsection 4 of NAC 687B.322, respectively.

     (f) A 2010 standardized benefit plan to supplement Medicare which is designated as High Deductible Benefit Plan F:

          (1) Must include only 100 percent of covered expenses following the payment of the annual deductible set forth in subparagraph (2) and the basic core benefits as defined in subsection 3 of NAC 687B.322, 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 defined in paragraphs (a), (c), (d), (e) and (f) of subsection 4 of NAC 687B.322, respectively; and

          (2) Has an annual deductible that:

               (I) Must consist of out-of-pocket expenses, other than premiums, for services covered by Standardized Benefit Plan F.

               (II) Must be in addition to any other specific benefit deductibles; and

               (III) Has a base which must be $1,500 and must be adjusted annually from 1999 by the Secretary of the United States Department of Health and Human Services 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.

     (g) A 2010 standardized benefit plan to supplement Medicare which is designated as Standardized Benefit Plan G must include only the basic core benefits as defined in subsection 3 of NAC 687B.322, 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 paragraphs (a), (c), (e) and (f) of subsection 4 of NAC 687B.322, respectively.

     (h) A 2010 standardized benefit plan to supplement Medicare which is designated as Standardized Benefit Plan K is mandated by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Public Law 108-173, 117 Stat. 2066, December 8, 2003, and must include:

          (1) Coverage of 100 percent of the Medicare Part A hospital coinsurance amount for each day used from the 61st through the 90th day in any Medicare benefit period;

          (2) Coverage of 100 percent of the Medicare 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) 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;

          (4) 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 (10);

          (5) 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 posthospital skilled nursing facility care eligible under Medicare Part A until the out-of-pocket limitation is met as described in subparagraph (10);

          (6) 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 (10);

          (7) Coverage for 50 percent, under Medicare Part A or B, of 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, until the out-of-pocket limitation is met as described in subparagraph (10);

          (8) Except for coverage provided in subparagraph (9), 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 (10);

          (9) Coverage of 100 percent of the cost sharing for Medicare Part B preventive services after the policyholder pays the Part B deductible; and

          (10) Coverage of 100 percent of all cost sharing under Medicare Parts A and B for the balance of the calendar year after the person has reached the out-of-pocket limitation on annual expenditures under Medicare Parts A and B of $4,000 in 2006, indexed each year by the appropriate inflation adjustment specified by the Secretary of the United States Department of Health and Human Services.

     (i) A 2010 standardized benefit plan to supplement Medicare which is designated as Standardized Benefit Plan L is mandated by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Public Law 108-173, 117 Stat. 2066, December 8, 2003, and must include only the following:

          (1) The benefits described in subparagraphs (1), (2), (3) and (9) of paragraph (h);

          (2) The benefits described in subparagraphs (4) to (8), inclusive, of paragraph (h), but substituting 75 percent for 50 percent; and

          (3) The benefit described in subparagraph (10) of paragraph (h), but substituting $2,000 for $4,000.

     (j) A 2010 standardized benefit plan to supplement Medicare which is designated as Standardized Benefit Plan M must include only the basic core benefits as defined in subsection 3 of NAC 687B.322, plus 50 percent of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in paragraphs (b), (c) and (f) of subsection 4 of NAC 687B.322, respectively.

     (k) A 2010 standardized benefit plan to supplement Medicare which is designated as Standardized Benefit Plan N must include only the basic core benefits as defined in subsection 3 of NAC 687B.322, plus 100 percent of the Medicare Part A deductible, skilled nursing facility care and medically necessary emergency care in a foreign country as defined in paragraphs (a), (c) and (f) of subsection 4 of NAC 687B.322, respectively, with coinsurance or copayments in the following amounts:

          (1) 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

          (2) The lesser of $50 or the Medicare Part B coinsurance or copayment for each covered emergency room visit. This coinsurance or copayment must be waived if the insured is admitted to any hospital and the emergency visit is subsequently covered as a Medicare Part A expense.

     8. On or after June 1, 2010, an issuer may, with the prior approval of the Commissioner, offer a policy to supplement Medicare or a certificate with new or innovative benefits in addition to the standardized benefits provided in a policy or certificate that otherwise complies with the applicable standards, and:

     (a) The new or innovative benefits must include only benefits that are appropriate to insurance to supplement Medicare, 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 simplifying policies to supplement Medicare;

     (c) New or innovative benefits must not include an outpatient prescription drug benefit; and

     (d) New or innovative benefits must not be used to change or reduce benefits, including a change of any cost-sharing provision, in any standardized benefit plan.

     9. As used in this section, “structure, language, designation and format” means style, arrangement and overall content of a benefit.

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