NAC687B.226. Minimum standards for coverage: Policy or certificate advertised, solicited, delivered, issued for delivery or renewed on or after July 16, 1992, and before July 30, 1992.

     1. A policy or certificate must not be advertised, solicited, originally delivered or issued for delivery, or renewed in this State as a policy or certificate to supplement Medicare on or after July 16, 1992, and before July 30, 1992, if it fails to meet or exceed the minimum standards established by this section. These standards do not preclude the inclusion of other provisions or benefits that are not inconsistent with these standards.

     2. A policy to supplement Medicare or a certificate originally delivered or issued for delivery, or renewed, in this State on or after July 16, 1992, and before July 30, 1992, must not:

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

     (b) 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.

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

     3. 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.

     4. A “noncancellable,” “guaranteed renewable” or “noncancellable and guaranteed renewable” policy must not:

     (a) 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 premiums; or

     (b) Be cancelled or denied renewal by the insurer solely on the grounds of deterioration of health.

     5. Except as otherwise authorized by the Commissioner, an issuer shall not cancel or refuse to renew a policy to supplement Medicare or a certificate for any other reason than the nonpayment of premiums or for a material misrepresentation.

     6. If a group policy to supplement Medicare or a certificate is terminated by the group policyholder and is not replaced as provided in subsection 8, the issuer shall offer to each certificate holder:

     (a) An individual policy to supplement Medicare currently offered by the issuer that provides comparable benefits to those contained in the terminated policy; or

     (b) An individual policy to supplement Medicare that provides only those benefits as are set forth in subsection 3 of NAC 687B.322.

     7. If a certificate holder is provided coverage under a group policy to supplement Medicare or a certificate and he or she terminates his or her membership in the group, the issuer shall:

     (a) Offer the certificate holder an individual policy to supplement Medicare pursuant to subsection 6; or

     (b) At the request of the group policyholder, continue coverage for the certificate holder under the group policy to supplement Medicare.

     8. If a group policy to supplement Medicare or a certificate is replaced by another group policy to supplement Medicare or another certificate which is purchased by the same person, the issuer of the replacement policy or certificate shall offer coverage to all persons who are covered under the policy or certificate that is being replaced on the date it is terminated. The replacement policy or certificate may not provide for the exclusion of coverage for preexisting conditions that were covered under the policy or certificate that is being replaced.

     9. Termination of a policy to supplement Medicare or of 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 predicated upon the continuous total disability of the insured, limited to the duration of the policy benefit period, if any, or to payment of the maximum benefits. Receipt of Medicare Part D benefits will not be considered in determining a continuous loss.

     10. If a policy to supplement Medicare eliminates an outpatient prescription drug benefit as a result of requirements imposed by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Public Law 108-173, 117 Stat. 2066, December 8, 2003, the modified policy shall be deemed to satisfy the guaranteed renewal requirements of this section.

     11. A policy to supplement Medicare that is subject to the minimum standards must provide at least the following benefits:

     (a) Coverage of Medicare Part A 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 for either all or none of the Medicare Part A inpatient hospital deductible amount.

     (c) Coverage of Medicare Part A eligible expenses incurred as daily hospital charges during use of Medicare’s lifetime hospital inpatient reserve days.

     (d) Upon exhaustion of all Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 90 percent of all Medicare Part A eligible expenses for hospitalization that are not covered by Medicare, subject to a lifetime maximum benefit of an additional 365 days.

     (e) Coverage under Medicare Part A for the reasonable cost of the first 3 pints of blood, or an equivalent quantity of packed red blood cells, as defined by federal regulations, unless replaced in accordance with federal regulations or already paid for pursuant to Part B. Plans K and L provide for 50 percent and 75 percent of the cost, respectively.

     (f) Coverage for the coinsurance amount, or, for services from a hospital outpatient department paid under a prospective payment system, the copayment amount, of Medicare eligible expenses under Part B regardless of hospital confinement, subject to a maximum calendar year out-of-pocket amount that is equal to the Medicare Part B deductible. This coverage must include coverage for Medicare eligible expenses for drugs used by an outpatient for immune suppressive therapy.

     (g) Coverage under Medicare Part B for the reasonable cost of the first 3 pints of blood, or equivalent quantities of packed red blood cells, as defined by federal regulations, unless replaced in accordance with federal regulations or already paid for pursuant to Part A, subject to the Medicare deductible amount. Plans K and L provide for 50 percent and 75 percent of the coverage of the cost, respectively.

     (Added to NAC by Comm’r of Insurance, eff. 7-16-92; A by R075-02, 9-20-2002; A by Div. of Insurance by R078-05, 11-17-2005, eff. 9-8-2005 for Plans K and L, and 1-1-2006 for Medicare Part D Prescription Drug Benefit; A by Comm’r of Insurance by R066-07, 1-30-2008; R049-09, 10-27-2009)